POM

Amputation by Tamiru D.
Presentation outline: March ,2020
 Definition
 Causes
 Types
 Level of amputation
 Assessment
– Physiotherapy treatment Pre-op Mx
– Decision making process in Sx
– Post-op PT
– Prediction of functional outcome
 Learning Objectives

By the end of the session students will be able to:

 Identify major factors leading to extremity amputation
 Describe and apply the levels of extremity amputation
and the functional impact
 Discuss and apply PT early post-operative examination,
goals & treatment of amputee pt.
 When presented with a clinical case study, analyze &
interpret patient data; determine realistic
goals/outcomes and develop a plan of care
 Amputation is the removal of an extremity by trauma, prolonged
constriction, medical illness or surgery.
 As a surgical measure, it is used to control pain or a disease
process in the affected limb, such as malignancy or gangrene.
 In some cases, it is carried out on individuals as a preventative
surgery for such problems.
 A special case is that of congenital amputation, a congenital
disorder, where fetal limbs have been cut off by constrictive
bands.
 In some countries, amputation of the hands, feet or other body
parts is, or was used as a form of punishment for people who
committed crimes.
 Amputation has also been used as a tactic in war and acts of
terrorism; it may also occur as a war injury
 Surgical procedures 
Initially, the arterial and venous supply are ligated to prevent
hemorrhage (bleeding). The muscles are transected and
the bone is sawed through with an oscillating saw.
Sharp and rough edges of the bone are filed down, skin and
muscle flaps are then transposed over the stump.
Distal stabilization of the muscles is recommended, allowing for
effective muscle contraction and reduced atrophy. This in
turn allows for a greater functional use of the stump and
maintains soft tissue coverage of the remnant bone.
Muscles should be attached under similar tension to normal
physiological conditions.
• myodesis: the muscles and fascia are sutured directly to the
distal residual bone for better prosthetic control
• myoplastic: suture to opposite muscle in the residual limb to
each other and to the periosteum or to the distal end of the
cut bone for weight bearing purposes
 What are the major causes for lower extremity
amputation?

• PVD=peripheral vascular disease (arteriosclerosis)

• Trauma
– MVA, gunshot
• Tumor/Cancer
• Congenital
 Causes of Amputation
- six categories (congenital & acquired)
1.peripharal vascular disease(any abnormal condition affecting the blood vessels
peripheral to the heart)
2.diabetes
3.trauma
4.infections
5.tumors
6.limb deficiencies
 terminologies of Limb deficiencies(congenital):
Amelia- absence of a whole limb
Apodia-absence of a hand or foot
Adactylia-absence of one or more fingers or toes and associated metacarpals or
metatarsals
Aphalangia –absence of one or more finger or toes
Phocomelia: "a congenital deformity in which the limbs are extremely shortened
so that the feet and hands arise close to the trunk"
 
 
Levels of Amputation
 Amputation level
Upper Limb Lower Limb
• Forequarter • Hemipelvectomy
• Shoulder Disarticulation • Hip Disarticulation (HP)
(SD) • Transfemoral TF(Above
• Transhumberal(Above Knee AKA)
Elbow AE) • Knee Disarticulation (KD)
• Elbow Disarticulation (ED) • Transtibial TT (Below Knee
• Transradial(Below Elbow BKA)
BE) • Ankle Disarticulation Symes
• Hand/ Wrist Disarticulation • Partial Foot PF (Chopart)
• Transcarpal(Partial Hand • Toe amputation
PH)
 LL Amputation nomenclature
Current name Previous used names
Partial foot amputation Chopart amputation
Lisfranc amputation
Ankle disarticulation Syme amputation
Pirogoff amputation
Through ankle disarticulation
Trans-tibial amputation Below-knee amputation

Knee disarticulation Through knee amputation

Trans-femoral amputation Above-knee amputation

Hip disarticulation Through-hip amputation

Trans-pelvic amputation Hemipelvectomy

Hindquarter amputation
Sacroiliac amputation
 What are the levels/classification of amputation?

 Transtibial (BK) 54%

 Transfemoral (AK) 32%
 Syme/foot 3%
 Hip disarticulation 1%
 Upper extremity 8% 4
 How level of amputation is selected?

 Preserve as much viable tissue/select most

appropriate level
 Pre-operative management

• “It is not to take but to make.”

• Early rehab involvement!
– Although same problem everywhere, not happening
or inconsistency in engaging rehab pre-op
• Peri-op mortality in LLA is high
• MI is the most common cause of post-op
mortality
• Cardiac function is relevant during rehab
because of required increased energy
expenditure
decision making in Sx
• “Soft tissue is more important than bone.”
 Post-op mx
• Wrong concept:
– Rehab only starts after the stump has healed
completely
• Consider x-ray of stump
• trial antiperspirant spray or roller for
problematic sweaty stumps?
• May need less wash (q2-3 days) of stumps
during colder months?
 Selection of Amputation Levels

 General guidelines
 Considerations with PVD
 Considerations with trauma
 Considerations with malignant tumor
 Considerations with deformity
 Considerations with congenital limb
deficiency/deformity revision
How does the level of amputation and age of patient affect
outcome?

 Higher the amputation, more difficult the rehab.

 Older/sicker the pt., more difficult the rehab.
 Age of Amputees

• > 61 40%
• 41-60 35%
• <40 25%
– 72% are males 4
 Who is on the Team?

 Pt.
 Dr.
 PT
 Prosthetist
 OT
 Social worker/case manager
 Dietician, nursing, etc.
 Vocational Rehab
 Responsibilities of the Team

 Evaluate pt.
 Initial training in prep. for prosthesis
 Prescription of prosthesis (if appropriate)
 Fabrication of prosthesis
 Delivery of prosthesis
 Evaluate fit of prosthesis
 Train in use, care of prosthesis
 Follow-up eval. For problems, possible changes,
needs of pt.
 Maintenance/replacement of prosthesis
 What tests/measures should be included in Pt Initial PT
examination?
 Ideally Mr. Howard would have had a referral to PT
BEFORE his amputation
 Definitive strength assessment of joint just proximal to
amputation can consist of only active, non resisted
antigravity motion until adequate healing of surgical site
i.e. will only be able to assess knee flexion and
extension to fair muscle grade; TF will only be able to
assess hip to fair muscle grade
 When incision healed & cleared by Dr., remember that
lever arm reduced & MMT grades could be inflated
 Do not apply pressure for MMT through dressing
 must be able to visualize suture line during 1 st
several weeks of preprosthetic prog.2
Pre-prosthetic Examination
Exam
 How can PT record measurements for Pts residual limb?
• Actual length
• Total length including soft tissue
– Measurements taken from easily ID bony landmark to the
palpated end of the long bone, to the incision line, or to the end
of soft tissue
• Medial joint line or tibial tubercle
• TF start measurement at at ischial tuberosity or greater trochanter
• Document which landmark you used!
• TT 5-6 inches ideal; TT less than 3 inches problematic for prosthetic
control and skin integrity
• Circumference: medial tibial plateau or tibial tubercle and
at equally spaced points to end of limb; TF=begin at ischial
tuberosity or greater trochanter clearly document
interval between measurements
– Prosthesis often made when distal limb circ= prox limb circ (<1/4
inch difference) 2
Poor Residual Limb Healing
 What are likely limitations for amputee pt

IMPAIRMENTS
FUNCTIONAL LIMITATIONS
• Pain
• Inability to walk
• Decreased strength,
• Inability to work
ROM, mobility
• • Inability to play
Decreased skin
integrity
• Decreased endurance
• Psychological issues
What should be included in the early post-op care
for an amputee pt

 ROM, positioning,
 skin care, edema control,
 isometrics, strengthening of UE’s/residual and
remaining limb
 pt. education,
 bed mobility,
 transfers, balance, etc.
 What are PT’s primary goals/outcomes for Pt’s
immediate post-operative period?

 Ensure optimal wound healing

 Early preparation of the limb for prosthetic fitting
 Maintain, increase mobility
 Improve endurance
 Care of remaining limb
 Maintain/increase ROM and strength
 How should PT inspect patien’s wound?

• Monitor residual limb for shape, incision healing/closure,

length, sensory integrity, volume, tissue integrity, color
temp., pain
• Easy to do with dressing change
– Record quantity/quality of drainage
• Normal for clear drainage first couple days  should decrease over
time; report red or darker blood or thickening discolored drainage with
odor to Dr.
• Traumatic (nondysvascular) pt. often ready to be casted
for training prosthesis day 10, others day 14 2
 How can you teach the Pt management?

 Once primary healing established, teach pt. scar massage

above & below incision (not across)
 Once wound well-closed, and no steri-strips, can begin
gently to mobilize scar itself
 Why is scar mobilization important?
– Tissues must be able to glide  adherence promotes shearing
forces which lead to skin breakdown
2
 What are common post-amputation sensations
amputee pt may experience?

 phantom limb sensation

– 70% will experience Numbness, tingling, pressure, itching, mild
cramp in foot/calf
 phantom limb pain
painful sensation perceived in the missing body part in the
case of an amputation, in the paralyzed part of a spinal
cord injury patient,
– Shooting limb pain, severe cramping, severe burning in
amputated foot/limb NOT psychological!
– higher amputation greater likelihood
– Evidence if pt. had significant dysvascular limb pain a surgery
are more likely to have phantom limb pain 2
 …continued phantom limb pain

Amputation type:
short ( 10% to 33% of sound side length );
medium (34% to 67% of sound side length);
long (68% to 100% of sound side length)
 How would you explain phantom limb pain to amputee
Pt?

 All nerves that once had branches to LE are still

present, but end at a new place. It takes time for
the brain to learn this fact.
 Also, these nerves may be very sensitive from the
amputation surgery as they are pulled and then
severed and allowed to retract.4
 What are some strategies for treatment of phantom limb
pain?

• Patient education before surgery

– Alert pt. to issues of safetywake up in middle of night p
recent amputation and fall when attempt to stand and walk
thinking both limbs are intact
• Careful inspection of limb to r/o neuroma or infected wound
• Compression, use of prosthesis, desensitization techniques, heat
• Medications, steroid injection, nerve block,
relaxation/hypnosisvaried effectiveness2
 PT management of Pain

 Time pain meds. So that pain control in optimal during PT

activities
 Pt. ed. on imagery & relaxation methods
 TENS: wound healing and phantom pain
 US, cold therapy, massage
 Wear prosthesis/compression bandages
– Varying effectiveness
– Pain management MUST NOT interfere with wound healing 2
 Why is compression bandaging important for ALL
amputees?

 Reduce edema
 Controls pain
 Enhances wound healing
 Protects incision during functional activity
 Facilitate preparation for prosthetic placement by
shaping and desensitizing limb
*1st 4 are required even if pt. not a candidate for
prosthesis2
 What options are there for edema control for amputee pt?
• Compression bandaging
– Rigid
• Rigid applied by surgeon in OR, removed 3-4 day, can then put new
with IPOP-allows limited TTWB in 2-3 days-prosthetist
• Best for controlling edema and pain
• Not good for pt. with significant risk for infection because wound status
not easily visualized unless removable
– Semi-rigid
• Prosthetist takes negative mold in OR or p rigid removed 3 day
• Polyethylene light weight, easy to clean, more durable than plaster
• Air bag
– Soft bandaging=ace bandage, compressogrip
• Once suture line healed (10-21 days), use shrinker TT/TF, Jobst for TF 2
RRD
Semi-rigid dressing
Shrinkers
 Principles of Ace-wrapping

 Distal pressure should exceed proximal

 Pressure applied on oblique turns only, No wrinkles
 Should be reapplied at least every 4 hours
 Don’t use metal clips—tape down
 No aching, burning or numbness—remove
 Wear 23 hours a day (remove for hygiene only)
 Wash daily, squeeze, don’t wring and air dry (need 2
sets)
 Continue use until pt. has definitive prosthesis & pt. can
leave stump unwrapped overnight and don prosthesis
without difficulty in the morning 6
 What are the most common contractures to prevent in
amputee pt?
• Transtibial
– Hip flexion
– Knee flexion
• Why?
– Long periods sitting in w/c, bed  position of comfort is one of
flexion
– Protective flexion withdrawal pattern associated with LE pain
– Muscle imbalances
– Loss of sensory input from foot in Wt Bearing 2
 What contractures are common in a transfemoral
amputee?
• Transfemoral
– Hip flexion
– Hip abduction
– Hip lateral rotation
 How can PT prevent contractures in amputee pt?

 Maintain knee in ext

– Bed  avoid use of pillows under residual limb
– W/C sliding board, elevating amputee hanger;
avoid long periods of sitting
 Lie prone
 PNF wheelchair, manual stretching
 AROM/PROM
Prevention of Contractures
 Strengthening For LE Amputee

 Maximization of overall UE/LE/TRUNK strength and muscular

endurance for safe, energy-efficient prosthetic gait, helps prevent
contractures, maintains mobility
 Post-operative muscle strengthening consists of isometric
contractions within a limited ROM at joint proximal to amputation
to minimize stress across incision
 Watch breathing  no valsalva!
 Recommend 10 second cx, followed by 5-10 seconds rest for 10
reps.\
 AROM of unaffected limbs day 1, affected-limb day 1-3; bed
mobility/transfers day 2
 As wound healing progresses, include large arcs of motion, active
resistive exercise, isokinetics, eccentric, etc.
6
 What should PT POC include for amputee pt?

 Hip ext., hip abductors/adductors, knee ext.

hip flexors, knee flexors as needed (may need to
stretch these short muscles)
 General strengthening/ROM of trunk and UE’s important
(esp. back ext. and abdominals, shoulder depressors and
elbow ext.)
 Aerobic ex. to increase endurance
 mobility
 Posture-COG shifted up, back and toward remaining
extremity
 Skin integrity prep residual limb/care remaining
 Balance 2
TT Exercises
TF Exercises
 Knee disarticulation
• Non-ambulatory pxs have different concerns and
goals than ambulatory pxs.
– How will the px transfer?
– What contractures are present?
– What contractures will occur?
– Consider surface area and support for sitting.
 Knee disarticulation
• For ambulatory pxs, KD is usually more
functional than a TFA
– Longer lever arm
– Balanced thigh muscles
– Improved suspension
– End bearing
– Lower proximal socket brim
– Sitting comfort
 Knee disarticulation
• Walking velocity (Pinzur, et al, Ortho, 1992 Sep)
– Slightly lower than TTAs, but significantly faster than TFAs
• Function (Hagberg, et al, PO Int 1992 Dec)

TTA TKA TFA

Don and doff 100% 70% 56%

Daily use 96% 76% 50%
>9hrs/day 54% 41% 22%
6-9hrs/day 17% 11% 6%
3-6hrs/day 13% 24% 28%
<3hrs/day 13% 12% 28%
No use 4% 12% 39%
 TFA
• Consider C-knee in the elderly population!
– Provides better gait
– Improved stability
– Improved walking speed
– Less falls
 TFA
• Hip flexion contracture
– 1st year: try to stretch to correct or lessen degree
of contracture
– After 1 year: provide prosthesis which will
accommodate to contracture
• Not cosmetic- but more functional
 TFA
• Who/When to prescribe a Prosthesis?
• TTA:
– Patient has their own knee power
– Prosthesis helps w/ transfer
– Prosthesis helps with STS
• TFA:
– Patient has no knee power
– Prosthesis has no knee power
– Transfers- often easier without prosthesis
– STS- prosthesis makes it more challenging
 TFA
• Before a TF Prosthesis is prescribed, patient
must master the following vital skills:
– Transfer independently (both in/out of bed, on/off
toilet)
– STS independently
– Walk in parallel bars or walker (one leg gait), for at
least 6-8 meters
 TFA
• Explain the vital skills and importance
• Offer prosthesis when patient masters skills
• Places challenge on patient and family
• Avoids arguments!
 Key Points(home take message)

 PT will ideally begin BEFORE pt. has amputation

 After a LE amputation, PT focus on pre-prosthetic training for
functional mobility, residual AND remaining limb skin care

– Positive approach to Surgery

– Positive approach to early rehabilitation
– Positive approach to prosthetics

any Questions?
Thank you for your attention!!!!