Post-Amputation and Rehabilitation Consideration

What issues should an amputee consider shortly after amputation and during the rehabilitation process?

Immediately following amputation, numerous things become the focus of the rehabilitation team and the new amputee. These include pain management, controlling swelling of the residual limb, shaping of the residual limb and the prevention of many other post-operative problems including infection. There is always a certain amount of post-surgical pain experienced by the amputee; this is often controlled with pain medications, which can be constipating. Additionally, surgery can often lead to a reduction in bowel function. The combination of these two factors may lead to severe constipation and discomfort, making the patient unwilling to participate in post-operative physical therapy.

An additional post-operative medical concern is the prevention of a respiratory infection. Typically after general anesthesia, there may be a tendency for the new amputee to develop a respiratory infection as a result of not taking deep breaths. For this reason, an incentive spirometer may be given to the patient, which encourages him to take deep breaths to prevent pneumonia. Additional preventive measures include frequent changes of position in bed to prevent the development of pressure ulcers, more commonly known as bed sores. These ulcers can result from poor nutrition as well as a lack of mobility and are more commonly seen in individuals with reduced ability to move in bed. Often a trapeze placed above the person’s hospital bed allows the lower limb amputee the capability of moving himself in bed, shifting weight to other parts of their body. Additionally, special boots may be put on the person’s normal foot to alleviate pressure off of the back of the heel, a very common location for pressure ulcers. Finally, the person may be given blood thinning medication or may have compression stockings put on the normal limb. These things are done to prevent a blood clot from forming in the vessels of the limb. These clots may break off and go to the lung, causing a life-threatening problem.

One of the most important goals soon after surgery is to protect the residual limb from injury while preventing infection of the surgical site. Swelling or edema may also occur and if left untreated can lead to an oddly shaped residual limb that may be difficult to fit into the socket of a prosthesis. One way to address several of these concerns is to use either a cast or also an immediate postoperative prosthesis or IPOP. With amputations across the shin bone (transtibial amputations), a rigid cast is placed around the residual limb extending up to and often above the knee. Occasionally, it can be removed so that doctors may inspect the surgical wound as it is healing. The advantage of having the cast go above the knee is that it also prevents a contracture from developing, a condition where the knee gets fixed into a bent position. If this flexion contracture is permanent, it may make wearing a prosthesis more difficult. The IPOP is typically applied immediately after surgery while the person is still in the operating room. Basically, this is composed of a temporary foot and pylon attached to a plaster socket that wraps around the limb. The plaster provides compression and prevents edema while it protects the surgical site from trauma and possible infection. A belt is incorporated into this plaster socket to provide some type of suspension onto the person. With the IPOP, the person can put a little bit of body weight on the residual limb almost immediately after surgery. However, if the person puts too much pressure on the limb, he risks opening the surgical site with devastating consequences.

After a few days, a significant amount of swelling goes away so the IPOP no longer will fit as well. At this time it will need to be removed and refitted. This is ideal since the physicians can check the surgical wound for healing and to be sure that no infection is present.

Another way to properly control edema and help shape the limb is with a rigid removable dressing or RRD. This rigid dressing can be removed for wound inspection but can also supply the needed compression that will properly form the residual limb. Once swelling goes down, socks can be put over the residual limb so that the RRD will continue to fit well. This type of compression dressing can be used for many different types of lower limb amputations, including transfemoral (across the thigh bone), knee disarticulations, transtibial and Syme’s amputations.

One other method that also provides compression to the residual limb after surgery involves using an elastic bandage. 

The advantage of this type of dressing rather than using an IPOP is that it is removable. Applying an elastic bandage necessitates training by the rehabilitation team and good hand-eye coordination. Often amputees with diabetes have poor vision as well as inadequate hand sensation with weakness due to neuropathy (see above), so this technique may be more cumbersome. The technique involves placing an elastic bandage in a methodical manner so that the greatest pressure is at the far end of the limb. Diagonal turns are then made closer up the residual limb so that the entire limb is covered and securely wrapped in the bandage.

Additional compression may be used with a shrinker sock, where a tube of fabric is applied around the limb in a cylindrical manner and then twisted at the end. The rest of the fabric is then folded back, fitting snuggly over the residual limb. Prefabricated shrinker socks are available but these also require some dexterity and strength in order to be applied properly.

All of these compression techniques should be used until the residual limb stays at one consistent size so that a socket can be fitted more easily. The amount of time that this takes varies, especially if there are other medical problems such as congestive heart failure or kidney failure. These conditions are associated with fluctuations in the amount of swelling that occurs in the residual limb. In general, it may take up to six to eight months for the limb to reach a stable size.

When can the new amputee start moving around?

Many may want to use a wheelchair or hop while others may want to know when they can use a prosthesis. Hopping on the normal leg requires a lot of stamina and may be too taxing for an older amputee. However, some younger single limb amputees find that hopping with the use of crutches is the best method for them to get around and prefer not to use a wheelchair or prosthesis. Hopping right after surgery should be discouraged, though, for several reasons. First, hopping may cause more swelling in the amputated side which is unhealthy for the surgical wound. Second, if the person is unaccustomed or doesn’t have the balance to stand on one leg for long periods of time, he may lose his balance and possibly injure himself or the surgical wound.

Additionally, people at risk for developing a wound on their sound leg may create too much stress or trauma by hopping around on it. If they develop a lesion or problem, they may lose the normal leg. Individuals with a prior amputation who now have a new amputation should not attempt to hop using the prosthetic limb on the older residual limb as this is unsafe and puts tremendous stress on the soft tissues. However, the individual can use the existing prosthesis to practice single-leg pivot transfers while waiting for a prosthesis for the newly amputated side. A more common way that some amputees begin moving around after surgery involves using a wheelchair. Some may elect to use a wheelchair permanently after they leave the hospital.

What are things the new upper limb amputee should focus on right after surgery?

Although many of these techniques and goals are important to do right after surgery, many should be continued for the rest of the life of the upper limb amputee. Many of these goals for an upper limb amputee are the same as that for the lower limb amputee immediately after surgery. These include reducing limb edema, shaping the residual limb, controlling pain, desensitizing the limb, adjusting emotionally and physically with the loss of a limb and begin performing physical and occupational therapy.

Control of limb edema and shaping the end of the limb can be accomplished with the appropriate dressing or compressive garment long with elevation of the limb. However, appropriate dressing of the surgical wound in the first few days following surgery should be left to the hospital staff (doctors and nurses). Later as the wound heals and once the individual receives permission, the new amputee should participate in the care of his own wound and residual limb.

Pain control can be a significant barrier to rehabilitation during this time. Residual limb pain, phantom sensation and phantom pain may be difficult to adequately treat, and each is described above. The medical team can help decipher which pain the individual has and what the appropriate treatment regimen is. The combination of the surgery itself, its associated ill-effects and the use of pain medications can hinder the rehabilitation process.