Unit 4 - Introduction to Limb Loss

Etiologies of Amputation

Etiology of Amputations

• Peripheral Vascular Disease (PVD) (82%)

  • Diabetes

• Trauma (16%)

  • Military, work-related, farming

• Cancer (1%)

  • Osteosarcoma

• Congenital (1%)

Limb Loss Statistics

• U.S.A.= 2.1 million people with amputations

• Expected to double by 2050

• 185,000 amputation surgeries/year (300-500/day)

• The number of amputations caused by diabetes increased by 24% from 1988 to 2009

• 85% of amputations result from a foot ulcer

• 55% of individuals with a unilateral dysvascular amputation

  • Amputation of the second leg within 2‐3 years

• African‐Americans up to 4x more likely to have an amputation

• Lifetime healthcare cost = approx. $509K, $361K without limb loss

Peripheral Vascular Disease (PVD)

• Leading cause of amputations:

  • Diabetes

  • Arteriosclerosis

  • Thromboembolism

  • Chronic Venous Insufficiency

  • Complicated by neuropathy

  • Amputation of the contralateral limb in 50% of patients in 2 to 5 years

Diabetes

• PVD more common in persons with diabetes than without

• Hypertension most predisposing factor for LE amputations in persons with diabetes.

• Complications

  • vision issues —> neuropathy —> infections

Age & Amputation

• Peak age range: 41-70 years old

  • 75% of all amputations > 65 years old

• Thus, most of your patients with amputations will be older adults!

The Diabetic Foot

• Assessment

  • In addition, to tests and measures, check footwear

• Care

  • Education on footwear

  • Keep the feet moist

  • Skin care

  • Skin inspection

Trauma

• Second most common cause of amputation (16%)

• Military, work or vehicle related accidents, farming

• Most common in young adult men

Cancer

• Account for about 1% of amputations

• Osteosarcoma

• Primarily affects children and adolescents

Congenital Limb Difference

• Represents just under 1% of amputations

• Slightly higher incidence of UE vs. LE

• Amniotic Band Syndrome

Factors Affecting Rehabilitation

• Health status

• Age

• Cognitive status

• Comorbidities

• Level of amputation

Amputations of the Toes

• Localized level of gangrene

• Neuropathic ulcer on plantar surface

• Infection or osteomyelitis of the phalanges

• Neoplasms

Ray Resection

• Vascular disease, Neuropathic ulcer, Osteomyelitis

• Surgery of choice for 4th and 5th ray removal

• Not surgery of choice if 1st and 2nd ray removed

• Orthotic or prosthetic shoe filler

Transmetatarsal

• Ray resection of all five metatarsals proximal to metatarsal heads

• Risk factors for poor healing

• Equinovarus

• Need toe filler in shoe

Lisfranc

• Disarticulation of tarsal/metatarsal joint

• Attempt to maintain transverse arch of midfoot

Chopart

• Disarticulation of midtarsal joint

• Between talus and navicular bones and calcaneus and cuboids

• Leaves calcaneus and talus intact

Equinovarus deformity

Requires custom footwear or orthosis

Symes

• Disarticulation of the talocrural joint

• Calcaneus and talus removed

• Bilateral malleoli are beveled

• Repositions fat pad/soft tissue under distal tibia/fibula

Transtibial

• Muscles crossing knee joint are preserved

• Fibula is cut approximately ½ to ¾” above tibia

• Anterior aspect of tibia is beveled

• Long posterior flap vs. equal length flap

ERTL Procedure

• Strut from the tibia to fibula

• Bone bridge will enhance weight bearing and increase total surface area for load transfer

• Increased reoperation rates

• Requires longer operative and tourniquet times than standard BKA

• New method = titanium strut

Knee Disarticulation

• Excellent and large weight bearing end

• Long lever arm controlled by strong muscles

• Increased stability of the patient’s prosthesis

• No bone cut and very few muscles

• Patella may or may not be spared

• Difficulty establishing equal prosthetic knee center

  • More distal knee center

Rotationplasty

• Usually from malignant neoplasm

• Ipsilateral ankle reattached at 180-degree angle

• Creates a knee joint

• Preserves growth plate to allow similar knee center at maturity

Transfemoral

• Preservation of length of femur

• Myodesis vs. Myoplasty

• Beveled end of femur

• Nerves cut for good coverage by muscle

• Traditional transfemoral surgery

• Osseo-integrated transfemoral

Hip Disarticulation and Hemipelvectomy

• Amputation undertaken to preserve life

• Significant body mass removed/blood loss

• Increased risk of blood clot of the intact limb

• Limited activity begins once patient medically stable

Common Techniques at all Levels

Myodesis and Myoplasty

suturing muscle to bone or muscle to muscle

Common Techniques at all Levels

Fibular versus tibial length

tibia always longer by ~2cm or 0.5in

Common Techniques at all Levels

• Beveling ends of bone for decreased heterotrophic ossification

• Flaps (according to vascular pathology generally)

Common Techniques at all Levels

Nerve resection

without trauma to the nerve - usually with a scalpel not scissors

Osseointegrated Transfemoral Amputations

• Trauma

• Osteosarcoma

• Initially from Sweden (1990’s)

• Implant directly into bone via coupling

• Has a stoma

Osseointegration

• Interface between tibia or femur prosthetic components

• No need for socket as the interface

• Allows for proprioceptive input, less heat retention, less skin breakdown from contact

• Infection risk

Neuromas

• A high rate of amputees acquire

• Some Treatment Options are TMR and RPNI. These surgeries involve proper nerve handling at the time of procedure

Neuroma Removal and Z-plasty

• *a painful growth of a bundle of nerves  usually arising from agitation

• Ill-fitting socket

• Irritation from surrounding tissues/structures.

• Surgical techniques:

  • Z-plasty

  • Balloon implantation for scar mobility

RPNI: Regenerative Peripheral Nerve Interphase

• Implants nerve segments into a denervated muscle graft.

• Generally, for lower extremity as the LE prostheses do not have the same ability to be controlled yet as UE prosthetic devices

TMR: Targeted Muscle Reinnervation

• Pioneered in 2002 (Kuiken and Dumanian) at Northwestern

• Originally for UE amputations to control prosthetics using normal muscle actions by routing to nearby motor nerves

• Re-route nerves to specific muscles to control the prosthesis for the shoulder joint, or for transhumeral amputations.

• Secondarily reduces phantom limb pain by creating neuromuscular junctions

Pre-operative Considerations

• Explore patient and family’s expectations

• Explain sequence of events (do NOT include time expectations)

• Reinforce realistic expectations

• Answer questions within PT scope

• Anticipate psychological status

• Clergy or rehab psychologist

• Pain control

Pre-operative Considerations

Prehab

• Cardiovascular

  • Intermittent claudication

  • Treadmill training

• Pre-prosthetic training

• Pre-prosthetic education

• Set up for evaluation within 1-2 days post-op

• AMPREDICT

  • VA decision tool, estimates mortality or re-amputation

  • Not for anyone with previous amputation

Peri-Operative Considerations

• Prosthetic education and realistic expectations

• Peer visitor (Amputee Coalition)

• Home evaluation

• Work and social environments

• Multi-disciplinary network

• Outcomes measures (applicable only)

Acute Care: Pain Management

• Alleviate acute discomfort

  • Biophysical agents

  • Medications as prescribed

• Learn precipitating and relieving factors for pain

• Generate motivation

• Team approach

Acute Care Goals

• Wound and residual limb healing

• Residual limb shaping 

• Potential protective dressing

• Contracture prevention

• Education

• Peer visitor when possible

All the above without complications!

Acute Care Examination

• Determine surgical techniques and visualize incision(s)

  • Myodesis, mypoplasty, direction of vascular/muscle flaps

• Motor learning, including previous use of AD or DME

• Bed mobility and CAN attempt transfer

  • Facilitates a rehab discharge

• Positioning of limb

  • Neutral? Contracture pattern developing?

• Limb measurements/observations

• Edema control method

Contracture Prevention for Amputations

• Positions of comfort

• Imbalance of muscle strength/intact

• Contracture pattern in transtibial

  • Knee flexion, can be hip flexion

    • Rarely (hip abduction and external rotation)

• Contracture pattern in transfemoral

  • Hip flexion, hip abduction, and hip external rotation

Skin Protection and Hygiene

Goal: to protect against the adverse effects of infection, and external mechanical forces including pressure, friction, and shear

Patient-Centered Management after an Amputation

• Individuals with a new amputation

• Patient-centered care and multidisciplinary teams

Edema control

• Pain control

• Wound healing

• Protect incision

• Facilitate preparation for prosthetics

Interventions: Edema Control

• Limb volume, shaping, and postoperative edema

  • Soft dressings

  • Pressure garments: Shrinkers

  • Removable Semi-rigid Dressings

    • Polyethylene

    • Zinc Oxide

Interventions: Elastic Wraps

Wrapping a limb

• Distal pressure > proximal pressure

• Pressure applied on oblique turns

• No wrinkles

• Do not leave any areas open

• Overlap ace bandage by ½ to 1”

Interventions: Elastic Wraps

Prevent contractures

• Transfemoral (hip flex, hip abd, ER)

  • Adductor roll

• Transtibial (knee flex, hip abd, ER)

Wrapping Advantages/Disadvantages

• Does not aid in the shaping of the residuum

• Requires ~5+ years to completely shrink and mature the residual limb

• To be effective, keep wrapped except for bathing

• Re-applied and cleaned a minimum of every 24 hours

  • Requires frequent reapplication

• Provides very minimal amount of compression (mmHg) and is inconsistent

Soft Dressing Advantages

• Low cost

• Easy wound inspection for healing and infection control

• some can be easier to don/doff

• tubular elastic can provide consistent compression

• elastic wraps can be modified for variable compression

Soft Dressing Disadvantages

• Can have poor control of edema if donned or sized incorrectly

• All have the need for frequent re-application

• Some are difficult for the patient to apply independently and correctly

• Inadequate trauma protection

• High potential to create a tourniquet

Spandagrip Advantages/Disadvantages

• Circular elastic bandage in the shape of a tube

• Can be cut to the desired length

• Multiple sizes

• Less mmHg than shrinker socks

• More consistent mmHg than elastic wraps

Shrinker Socks

• Sometimes easier than an ace wrap

• More expensive initial cost

• NO USE until the staples or sutures are out

• Provides about 30-40mmHg

• New shrinkers as volume reduces

Shrinkers Advantages

• Easier to use for transfemoral

  • Slipping is minimized because the hip spica (for transfemoral) aids suspension

• Better compliance than with elastic bandages

Shrinkers Disadvantages

• Increased expense

• Multiple shrinkers as the residual limb loses edema/volume

• Does not prevent an adductor roll

• Tends to be uncomfortable over sensitive areas or bony prominences

• Requires hand strength and dexterity to apply

Dressing Advantages/Disadvantages

Combination Dressings

• If necessary, ace wraps may be applied over shrinker socks but often cannot be tolerated for long periods of time.

• Some prosthetists suggest wearing a silicone sleeve over their shrinker sock to increase mmHg compression for fitting.

NOTE: Please be aware of skin breakdown, skin sensitivities and tolerance to fluid re-absorption

Interventions: Edema Control

IPOP: Immediate Post Operative Prosthesis

• Casted by surgeon and prosthetist in the OR

• Sometimes removable

Interventions: Edema Control

EPOP: Early Post Operative Prosthesis

• Always removable

• Off the shelf, not custom made

IPOP/EPOP Advantages

• Improved shaping, healing time

• Protection from trauma

• Maintenance of strength and function

• Prevention of contractures

• Early return to balance and ambulation tasks

• Improved social and emotional well-being

• Shorter hospital stays and overall recovery time

• Earlier identification of the functional level that determines components

• Reduction in severity of phantom pains

IPOP/EPOP Disadvantages

• Potential for risk for falls or injury

• Limited WB can inhibit healing

• Ambulation is sometimes encouraged too soon

• Difficult to attain proper fitting and pressure relief

• Difficult to inspect the limb if it is not removable

• Difficult to match the sound side

• NOT indicated for incontinence

Semi-rigid advantages

• Compared with rigid dressings and IPOP are less expensive

• Improved edema control

• Improved trauma protection

• Remains relatively secure during functional mobility

• Minimal movement inside the dressing

Semi-rigid disadvantages

• Need for trained personnel to apply dressing initially and for training

• Lack of easy inspection to monitor healing (not removable if Unna Paste)

• Can be unsuitable for incontinent patients

Limb Measurement

• Measure girth routinely to control and monitor edema

• Measure redundant tissue (“dog ears,” adductor roll)

• Residual limb shape (bulbous, cylindrical, conical)

• Assessment of type and severity of edema

• Assess for other skin problems

• Myodesis and myoplasty operative techniques can determine limb shape, muscle mass retained and therefore determines muscle strength

• Initially measure residual limb length in terms of a long, medium or short residuum

Interventions for Persons with Recent Amputations

• Skin Care and Scar Management

• Range of Motion and Flexibility

• Muscle Performance

• Endurance

• Postural Control

• Wheelchairs, Seating, and Adaptive Equipment\

• Bed Mobility and Transfers

• Ambulation and Locomotion

• Care of the Remaining Limb

Examination of a Patient

• Complete patient-client history

• Systems Review

• Tests and measures

Patient-Client History Review

• Demographic and Sociocultural Information

• Developmental Status

• Living Environment

• Health, Emotional, and Cognitive Status

• Medical, Surgical, and Family history

• Current Condition

Systems Review

• Cardiopulmonary and cardiovascular

• Musculoskeletal

• Neuromuscular

• Integumentary

• Communication

Tests & Measures

• Acute postoperative pain

• Phantom sensation and phantom pain

• Residual limb length and volume

• Integumentary integrity and wound healing

• Circulation

• ROM and muscle strength

• Joint integrity and mobility

• Muscle performance and motor control

• Upper extremity function

• Aerobic capacity and endurance

• Attention and cognition

• Sensory Integrity

• Mobility, locomotion, and balance

• Posture, ergonomics, and body mechanics

• Self-care and environmental barriers

• Postoperative complications

Common Outcome Measures Used in Assessment

• Performance Based

  • Amputee Mobility Predictor

  • No Prosthesis (AMP-noPro)

  • Timed Up and Go (TUG)

  • Two Minute Walk Test (2MWT)

• Self-report measures

  • Houghton Scale

  • Prosthetic Evaluation Questionnaire (PEQ)

  • Prosthetic Limb Users Survey of Mobility (PLUS-M)

Evaluation, Diagnosis, & Prognosis

• PT diagnosis

• Plan of care: Prognosis

• Plan of care: Determining appropriate goals

Triple Threat

• Loss of function, loss of sensation, and loss of body image

• Many amputees adapt well

  • Resilience

  • Ingenuity and dedication of caregivers

• The observed psychological response to amputation is determined by many variables

  • Psycho-social variables

  • Biological variables

  • Social drivers of health

Psychosocial Support

• Single/widowed individuals

  • Increased psychological distress

  • Increased difficulty in adapting to amputation

• Supportive partner is ideal

  • Assumes a flexible approach

  • Takes over functions as needed

  • Allows autonomy and independence while supportive

  • At all times maintains the self-esteem of the individual

• Parents remain a major source of support for children and young adults

• Peer acceptance beyond the family is critical for adaptation

Psychosocial Variables: Older Adults

• response to limb loss depends on:

  • Generational/familial responses to trauma

  • Social support and network

  • Job or volunteer status

  • Medical comorbidities

• at greater risk for:

  • Depression

  • Polypharmacy

  • Frailty

Age Considerations

Infant/Toddler

• Child will adapt and meet motor milestones and usually quickly learn to use prosthetics

• Usually fit with a prosthesis as soon as they are developmentally ready

• Be aware that parents may be in shock, denial, or experience feelings of guilt

Age Considerations

Pre-teen/teenagers

• develop a “unique” identity

• Traumatic to lose a limb when one’s identity isn’t yet established

• Be sensitive to the need for increased modesty in teenagers and young adults

• Sensitive to peer acceptance and rejection (“no one is going to look at/befriend me”)

• They want to be involved with other young amputees

• Sexuality can be an “unspoken concern

Age Considerations

Middle Age & Older Adults

• Impact on occupation/financial status is major concern

• Desire to maintain independence is a critical issue in this population

• May have a sense of failure if loss of limb was due to unhealed wound

Economic Impacts

• Individuals with occupations that require high degree of motor skill most vulnerable

  • Unemployment

  • Underemployment

  • Inability to become employed

• If re-employment is likely - Office of Vocational Rehabilitation (VR)

  • Voc (pronounced Voke) Rehab

  • State funded program

  • Individuals with disabilities find and maintain employment

Influence of Psychosocial Aspects in Physical Therapy

• Change in self-concept relative to body image

• Effect of pain or altered sensation

  • incisional, body and/or phantom

• Age considerations

• Financial impacts

Depression in the Amputee Population

• Strong link between psychosocial adjustment and rehab outcomes:

  • High-levels of anxiety and depression in amputee population

  • 28.7% with severe depressive symptoms (Darnall et al 2005)

  • Individuals with higher levels of education have less depression

  • Only 44% received mental health service

    • Dreams/nightmares are common in first month post-operatively

      • If persistent = poor adjustment

Personality Styles

• Narcissism with investment in physical appearance

  • Tend to react negatively to loss of limb

• Co-dependent individuals may cherish sick role

  • May find welcome relief from pressure and responsibility

• History of depression are susceptible to dysphoria

  • Notions of basic defectiveness

  • Can result self-punishing behaviors

Self-Perception: Body

• Learning three (3) body images

  • Intact, amputee, amputee with a prosthesis

• Self perception about body image is influenced by:

  • Age

  • Cultural beliefs

    • Social stigma, religious or spiritual beliefs, locus of control

  • Personality type and coping style

• How a person responds to this change after an amputation may affect:

  • Recovery process

  • Personal relationships

  • Living environment

  • Vocational goals

  • Leisure activities

Coping Styles Influence Adaptation

Livneh et al suggest 4 basic styles:

• Active problem-solving:

  • Seek support

  • Reframe the problem

  • Make plans to adapt

• Emotion-focused:

  • Wishful thinker

  • Self-blame

  • Socially withdraws

• Problem disengagement:

  • Problem avoidance

  • Drugs/alcohol abuse

  • Hyper-religion

• Cognitive disengagement

  • Total denial

Sexuality

• An area of some questions and concerns especially in the young adult

• Rejection by a partner

• Physical impact due to loss of body part

• Prosthesis is of no use in this area

• Self-consciousness

• Loss of sensation depending on cause of amputation

• Do not overlook discussion in this area – self-help groups may provide best source of information

Pain Considerations

• Phantom pain or other Nerve pain

• Pain from their prosthesis

• 70% at some point complain of back pain. Many times this is due to altered gait patterns

• Leg length discrepancies (appropriate or inappropriate)

• Incorrect fit causing amputees to accommodate to a prosthesis

• Sound limb pain often due to overuse for daily activities or transfers when prosthesis is removed

Prosthesis Related Pain

• Socket should be designed to avoid pressure sensitive areas

• Total contact socket distributes weight of the limb across large area of tissue

• Indentations in tolerant regions used to relieve pressure sensitive areas

• Socket will require modifications as residual limb changes:

  • Muscle atrophy

  • Edema management 

  • Weight change

  • Length change

  • Volume change

Phantom Limb Sensation

• Feeling that missing limb is still present

• Variety of sensations: itch, tactile touch, pressure, temperature, position, and/or movement

• Non-painful

• Estimated that 80-90% of patients will have some phantom sensation

• May persist many years after amputation

• Few studies completed to explore impact on function

• May benefit or hinder patient depending on a multitude of factors

Phantom Limb Pain

• Painful sensations arising from the missing portion of the limb

• Estimated that 45% - 85% experience phantom limb pain

  • High variation in different populations being studied and no distinct instrument to assess

• Usually described as sharp, shooting, tingling, stabbing

• Onset is typically in first few days after amputation

• Episodic or intermittent – not typically constant

• Usually described as moderate in intensity – a 5 – 6 on a 10-point VAS, but great variation in studies

• More information is known about LE than UE phantom limb pain

War Amps of Canada: Phantom Pain

Interventions for Phantom Pain

• Pharmaceuticals: anti-depressants, anticonvulsants, opioids includes cannabinoids

• Mirror box therapy

• Mental imagery

• Virtual reality

• Nerve Stimulator: may require surgery

• Acupuncture

• Targeted Muscle Reinnervation (TMR): surgical 

• Regenerative Peripheral Nerve Interfacing (RPNI): surgical

Neuromas may Cause Phantom Limb Pain

• Axons from excised nerves attempt to regenerate and grow

• Epineural sheath damaged cannot direct regrowth

• Nerves start to grow but get bundled, form scar tissue

• Creates pain with pressure, stretching, touch

Surgical Approaches for Phantom Limb Pain

Targeted Muscle Reinnervation (TMR)

involves surgically connecting a severed nerve to a nearby muscle. Provides new target for nerve regeneration

Surgical Approaches for Phantom Limb Pain

Regenerative Peripheral Nerve Interface (RPNI)

a surgical technique used to prevent and treat pain associated with nerve injuries, particularly in amputations