Post Op, Partial Foot, + Ankle Disartic

phases of rehab

preoperative

amputation surgery + wound dressing

acute postsurgical

preprosthetic

prosthesis prescription + fabrication

prosthesis training

community integration

vocational rehab

follow up

preoperative phase

medical + body condition assessment

pt education

surgical discussion

functional expectations

phantom limb discussion

intro to multidisciplinary team

peer support + counseling

amputation surgery + wound dressing phase

residual limb length determination

myoplastic closure

soft tissue coverage

nerve handling

rigid dressing application

limb reconstruction

staples/sutures used to close the limb

limb is very tender, noticeable edema, more bulbous shaped

surgeon may want to be the one to remove the dressing

staged amputations → open amputation, delayed closure

acute postsurgical

residual limb shaping

shrinking, compression can assist w healing + pain reduction

increasing muscle strength

restoring pt sense of control

control of acute pain can help chronic pain from forming

distinguishing from residual limb pain + phantom pain

early mobilization, transgers

limb healing

inpatient rehab, skilled nursing facility, at home therapy

preprosthetic phase

wound healing

pain control

proximal body motion

emotional support

phantom limb discussion

staples/sutures for ~3 wks, 4-8 in dysvascular

may req new shrinker size

desensitization → gentle massage, tapping, different textures

PT, strengthening → cardiovascular endurance, prevent contractures, pt education

prosthesis prescription + fabrication

team consensus on px rx

once incision is well healed, skin in good condition

functional shape for socket

edema + volume stabilization

quicker the pt receives a px, the better the outcomes

wt bearing activity will accelerate limb edema reduction

day to day volume fluctuations can be a challenge → sock ply mgmt education, have extra socks at all times esp during exercise

minimize time w/o compression → use gel liner, shrinker

consider having pt rest limb on stool when adjustments are made

prosthesis training phase

training to increase wearing time + functional use

O2 uptake for individuals w/unilateral transtibial amputation can be 10-40% higher than nonamputees

cadiopulmonary endurance may need to be developed

new pts may onlu be allowed to wear px during PT + gradually increase wear times

skin inspection

graduate to demonstrating ability to manage px + sock ply

neuropathy + dysvascular. pts need shorter intervals of wear initially

gait training is main focus of PT

prosthetist should provide basic instruction during dynamic alignment + delivery appt

communicate as pt progresses

pads to accommodate volume, alignment changes as necessary

gait/balance improvements, strengthening, ROM gains

community integration phase

resumption of family + community roles

regaining emotional equilibrium

developing healthy coping strategies

resuming recreational activities

return to new normal, amputation req revision to body image

adjustments can depend on many factors → planned vs unplanned surgery, age, developmental stage, social support

psychological challenges → high rates of depression, anxiety, PTSD mental health support needed as this stage

pt motivation is a key determinant of success

vocational rehab phase

assess + train for vocational activities

assess further educational needs or job modification

follow up phase

lifelong px, functional, + medical assessment

emotional support

more freq initially then spread out as limb matures

should still follow up annually even as limb matures

if limb volume changes follow up → post op edema subsides, muscle atrophy, wt loss

socket replacement → may req multiple as limb continues to mature, timeframe is highly variable + may depend on post op dressing chosen, pt size, pt weight, activity level, comorbidities

LEAP protocol

lower extremity amputation protocol

developed for vascular amputation

decreases length of stay

improves time to ambulation

phantom limb pain

pain perceived in section of limb no longer there

not fully understood

combo of CNS + PNS

can feel like throbbing, cramping, stabbing, burning

telescoping → phantom foot moves closer to the end of the residual limb over a period of time

medication, mirror therapy

phantom limb sensation

not painful but sensation that the limb is still present

can feel like numbness, tingling, itching

postsurgical wound drainage

initially sanguineous, transitions to serosanguineous, then serous

purulent may be sign of infection, likely req antibiotics, may need revision surgery

long term complications

pain → residual limb pain due to socket fit issues or HO, neuroma pain, phantom limb pain

may req revision surgeries

other health issues → overuse, low back pain

partial foot

most common amputation surgery, ~50% done by podiatrists

preferential surgery compared to more proximal amputations historically

retains distal wt bearing

similar outcomes to transtibial → gait speed, energy cost, QoL

causes → some trauma, mostly dysvascular

higher complication rates than transtibial → infection, wound breakdown, revision surgery

partial foot levels

toes

ray resection

transmetatarsal

lisfranc

chopart

toe amputation

75% of all partial foot amputations

loss of hallux results in greatest deficit

ray resection amputation

toe + metatarsal

narrow forefoot must be accommodated w/ox or shoe

transmetatarsal amputation

met heads removed + variable length of metatarsals remains

once met heads are removed, power generation/propulsion is lost

likely revised to transtibial if complications arise

lisfranc amputation

at tarsometatarsal joint

results in equinovarus deformity

chopart amputation

at midtarsal joint

all DF attachments are transected, req tendon transfer

achilles lengthening

results in equinovarus deformity

loss of anterior lever arm → toe lever

shortened step lengt, less energy efficient gait

loss of wt bearing area → P=F/A, pressure at distal limb increases, shear

limb length discrepancy → arches are gone, calcaneal angle decreases, PF angle increases, decreased limb length

tx goals for partial foot amputations

balance

protect distal end from friction, shear, pressure

gait symmetry → increase toe lever, allow CoP to progress beyond residual limb, stiffen forefoot, restrict DF in late stance, + transfer force to proximal limb

propulsion → ankle power greatly reduced once met heads are compromised

partial foot device options

the more proximal the amputation, the more substantial the device

partial foot shoe insert w/longitudinal arch + toe filler

partial foot molded socket ankle height w/toe filler

partial foot molded socket tibial tubercle height w/toe filler

partial foot shoe insert w/longitudinal arch + toe filler

in shoe submalleolar

for toe, ray, maybe transmetatarsal

toe filler fills in remaining space in the shoe

prevents contact btwn toe box + residual limb

maintains position of residual foot

redistribute pressure away from sensitive distal end

reduce skin breakdown

shoe serves as suspension

add ons/shoe mods → carbon plate, steel shank, rockers

partial foot molded socket ankle height w/toe filler

ankle height submalleolar

unable to effectively increase the toe lever

doesn’t restrict DF or transfer force to proximal limb

maintain ankle ROM but little added function

more of cosmetic option → difficulty covering w/insurance

partial foot molded socket tibial tubercle height w/toe filler

any tibial height

for transmetatarsal, lisfrance, chopart

option for immobilizing → arizona, total contact, protect residual limb, shape of shoe serves as filler

goal → improve function/propulsion, increase toe lever, improve gait symmetry

3 design features

stiff forefoot to support body wt → carbon footplate, chopart plate

restrict DF in late stance

transfer force to proximal limb

ankle disarticulation

retains distal heel pad for wt bearing

arguably the most functional level of amputation bc length of the residual limb leaves a significant lever arm to distribute forces + control px device

little functional disparity w/nonamputee

symes is more energy efficient than partial foot

symes

pros → longer lever arm for px control, as much distal wt bearing as possible, heel pad is preserved, may allow for lowering of trimlines, able to ambulate short distances w/o px, can achieve anatomical suspension via malleoli, surgery + healing may be less involved than transtibial, no bony overgrowth in pediatrics

cons → limited space for components, endoskeletal parts/px feet, cosmesis (bulky), full width of malleoli, plus interface plus socket, can appear wide near ankle, heel pad can migrate, limits wt bearing until well healed

other surgical variations

pirigoff, boyd

pros → enhance ambulation w/o px, excellent wt bearing, close to original limb length, both believed to help w/heel pad stabilization, retaining part of calcaneus

cons → fit px foot under socket, may req lift on contralateral side

socket designs

casting considerations → self suspending, may cast in partial wt bearing if utilizing distal wt bearing capability in socket

self suspending via pad or soft insert → foam insert stovepipe, foam buildups create cylindrical shape, need slits for donning

removable window/door → socket cut out allows bulbous limb to pass then add door + tighten straps, medial or posterior door placement

expandable wall → internal air bladder, complex to fabricate

roll on liner w/expulsion valve → custom gel liner w/suction

components

limited space for distal componentry

may not allow for endoskeletal parts

direct lamination → alignment

feet → low profile, stiff, little energy return, posterior mount for increased dynamics + spring