Acute post-surgical management of the amputee

Introduction

It is important to remember that the sooner rehabilitation begins, the greater the likelihood of success. Patients require early physical therapy to avoid complications such as joint contractures, pathological scarring and depressed psychological status. main Postoperative complications included cardiovascular stump pain and phantom edema contracture and wound dehiscence. [1]

Goals of acute postoperative rehabilitation

• Obtain maximum independence
• Prevent oedema
• Maintain joint ROM
• Prevent amyotrophy (muscle atrophy)
• Increase the muscular activation
• Prevent muscular weakness
• Prevent bronchopneumonia
• Prevent pressure sores
• Control pain
• Sensory reeducation
• Support the client psychologically

Before any treatment is given, a physical therapist will conduct an assessment. At this early stage, a functional assessment including upper extremity, lower extremity and trunk can be performed to assess the patient’s potential for activities such as wheelchair transfers Mobility and walking (with or without prosthetics) [1]

Treatment modalities

Treatments to prevent complications include:

• Breathing exercises
• AROM
• Resistance exercises
• PROM
• Desensitising techniques
• Stump management
  • Dressings
  • Prevention of oedema
  • Wound healing
  • Pain
• Bed mobility and transfers
• Positioning
• ADL
• Walking and wheelchair use

Breathing exercises

Deep breathing exercises and relaxation exercises will help increase lung capacity, reduce anxiety and prevent bronchopneumonia.

Active range of motion (AROM)

Amputation side (from postoperative day 1, unless postoperative dressing restricts movement):

• First hip flexion and extension ADD ABD
• Knee flexion exercises (for below knee amputation (BKA)

Amputation side (from postoperative day 3)

• To reduce edema, BKA amputees should alternate knee flexion and knee extension.
• Knee dislocation and TF amputee should alternate hip flexion and hip extension ADD and ABD.

These active exercises must be done regularly during the day (10 repetitions per hour). Bilateral mobility usually achieves a more intense contraction on the amputated side.

[2][3]

Resistance exercises

From the 1st post op day

• Quadriceps Isometric Contraction (BKA)
• Isometric gluteal adductor contraction and hip internal rotation
• Sound Lower Limb Strengthening Exercises (Ongoing)

From the 3rd post-op day

• Resistance exercises of the upper limbs
• Resistance exercises of the torso

[4]

PROM

Passive extension of the TT stump. [5]

The physiotherapist’s hands should be kept as close as possible to avoid touching the very sensitive end of the stump.

Massage percussion desensitization and scar mobilization

Desensitization is thought to reduce pain, aid tolerance and tactile sensation in the residual limb, and may help the amputee adjust to his or her new body image that now includes the loss of the limb. Massage and slapping can start early, on soft dressings, or on closed. [6] All of these techniques can be performed by a therapist or taught to a patient/family member. Patients are also instructed on how to perform desensitization and distraction techniques to reduce phantom pain.

• Massage[6]
  • Using 1 or 2 hands, gently knead and massage the entire residual limb. Be careful in the stitched area.
  • After the stitches or clips are removed, you can increase the pressure on the underlying muscles and soft tissues.
  • Use for 5 minutes 3-4 times daily or as needed to reduce phantom pain.
  • Gently massage the proximal stump, including pressure points in the groin area
• Tapping [6]
  
  • Tap the stump with your fingertips (not your nails).
  • Gently tapping on the suture while the suture or clip is still in place
  • This can also be done with rigid or soft dressings
  • Once the stitches have been removed, a flapping motion can be performed on the residual limb
• Desensitisation[6]
  
  • This helps to make the stump less sensitive to touch and will improve tolerance to touch.
  • 2-3 times a day when the soft dressing comes off (this can be done during or after bathing)
  • Begin by gently rubbing the skin with a soft material, such as a cotton ball, in circular motions.
  • Do this by using a rougher material, such as a paper towel, and then using a towel or cloth until you can tolerate the material.
• Scar Mobilisation[6]
  
  • This will prevent the scar from sticking to the underlying tissue, which can cause pain and blisters when the patient starts wearing the prosthesis.
  • Perform with soft dressing or compression off.
  • Patient can do this while bathing every day
  • Place two fingers on the bony part and keep the fingers in the same position in a circular motion for 1 minute.
  • Repeat this around the bones of the stump
  • After the wound has healed, the scar tissue can be moved through the incision line

[7]

Stump management

The ideal stump is a well-healed stump with good vascular supply, soft and mobile scar, minimal pain and minimal edema, long enough for biomechanical leverage but not too long to limit Choice of prosthetic components and large surface area for pressure distribution. during surgery Plays an important role in creating an ideal residual limb and physical therapy is needed to maximize the chances of achieving this ideal.

One of the main acute postoperative factors affecting prosthetic fitting time and speed of recovery is wound healing of the stump, especially in vulnerable vascular compromised populations [8]. Residual limb edema is also a common complication after LLA [9]. Controlling the amount of postoperative edema is critical to promote wound healing, control pain, protect the incision during recovery, and assist in repairing the stump for repair [10]. Soft dressings or nonadhesive elastic bandages are traditionally used to prevent edema residual limb after surgery, but there is no evidence to support the use of these bandages [11] [12]. Immediate postoperative use of rigid or semirigid dressings to prevent acute edema is becoming increasingly popular in developed countries and is well supported by literature evidence [10][11].

Post-operative dressing

Postoperative dressings are used to protect the limb, reduce swelling, promote limb maturation, and prevent contractures. There are two main types of post-operative dressings:

• Soft dressings
  • Descriptive studies have shown several disadvantages of soft dressings, such as high local or proximal pressure, easy loosening or detachment, limiting mobility and prolonging hospital stay.
  • Controlled studies found no significant differences in uncomplicated healing rates, postoperative pain, eventual prosthetic use, and frequency of mortality between soft and hard dressing types [13].
• Rigid Dressings – For many years, rigid dressings have been used as a best practice in postoperative stump management.
  • They come in 2 types:
    • A non-removable thigh length cast protects the residual limb and keeps the knee extended; and
    • A removable rigid dressing in which a plaster cast wraps the residual limb below the knee, allowing the amputee to bend the knee, and is easily removed to inspect the residual limb. (See [13] for evidence of use)
  • Some of the reported benefits of rigid dressings include promoting wound healing, shaping the residual limb for pain management, preventing trauma during falls, controlling residual limb volume, and increasing the speed of prosthetic fitting [10][11].
  • The usual method of application of a rigid dressing is a plaster cast rigid dressing, usually applied in the operating room under anesthesia. This approach has been shown to be effective, but surgeons often choose not to choose this rigid dressing method because it is time-consuming and requires some Application Tips[14]
• Removable rigid dressing (semi-rigid dressing)
  • Another vacuum-formed removable rigid dressing has been shown to be as effective as conventional rigid dressings in a randomized controlled trial and is a useful alternative to the plaster casting method [8].
  • The advantages of this removable rigid dressing include ease of application and ease of wound inspection [8][15]. This dressing can be used for 5-7 days after surgery.
  • Prefabricated removable dressings also exist (see photo)
  • Reichmann et al reviewed the available (15) articles on the use of rigid removable dressings (RRDs) and found the following:[15]
    • RRD is better than soft dressings because it improves healing time, reduces residual limb edema shaping, prevents knee flexion contractures, and prevents trauma to amputations.
    • According to this review, non-weightbearing RRD should be the first choice of treatment after below-knee amputation surgery

Oedema control (shrinking)

In the BACPAR guidelines for the management of edema in lower extremity amputee [16], they concluded that rigid/semi-rigid dressings should be used when expert time and resources allow, based on the best currently available evidence; these benefits are described in the literature There are detailed records. PPAM Assisted Compression Socks and stump boards have been shown to have some evidence base for controlling edema and may be used additionally or in the absence of rigid dressings based on clinical judgment. However, these modalities are not necessarily primarily used to control edema. their advantages include Preparing for Physical Rehabilitation Reducing flexion deformity and maintaining/improving muscle tone are important components of amputee rehabilitation. Compression stockings and PPAM aids are the only tools available to transfemoral amputees. Although compression stockings are Widely used as a form of edema control, but there is very limited evidence on when to apply it, who should assess its appropriateness and how often it should be worn. Suggests that further research is needed to provide clinicians with more clarity these fields. [16]

Read the full guidelines here

Another option is the use of postoperative silicone liners:[17]

• Use after removing removable hard dressing
• Applies the same level of compression to the residue even if a different person applies it
• It reduces edema and shapes residue from prosthetic fittings
• helps with pain relief
• fast track the rehabilitation process
• It can be sterilized
• The liner is sized according to the circumference of the residue and can be replaced when the edema decreases
• Cons are: Expenses as edema subsides Requires use of another size silicone liner Not readily available

Wound healing

Wound healing has always been a concern, especially in people with vascular disorders. Adequate control of stump edema aids in healing, but some evidence also supports the use of low-level lasers to promote and accelerate wound healing in diabetic patients [8]. However, the exact dosage for optimal effect has not been determined.

Pain

Pain is a very common physiological stressor that occurs in the acute postoperative period and can affect a patient’s ability to learn new skills [10]. Adequate control of pain levels in new amputees greatly facilitates their early recovery [10]. physiotherapist This should be taken into account and the patient treated immediately after receiving pain medication. Postural control of residual limb edema is also helpful in relieving acute postoperative pain [10]. Various physical therapy interventions for phantom limb management pain, but there are few studies demonstrating their efficacy in the research literature [18]. One of the few physical therapies that has been shown to be effective in treating phantom limb pain is Transcutaneous Electrical Nerve Stimulation (TENS) 60 minutes [9].

See the Pain Management for Amputee page for more information.

Patient information

A collection of helpful patient information guides from the Amputee Alliance.

• Perioperative_Pain_Management_Preview
• Avoiding_Secondary_Pain_Preview
• Living_with_Residual_Limb_Pain_Preview
• Living_with_Phantom_Limb_Pain_Preview_(1)
• Care_of_Your_Wounds_Preview

Bed Mobility 

• Bridging
• Rolling
• Sitting up in bed
• running to one side when lying and sitting
• Moving up and down on the bed.
• Arm push-ups (after drain removal)
• Sit on your side or balance with your legs on the bed [19]

• 
  

  Bridging

•  

• Rolling from one side to the other

•  

• Sitting up: patient bilateral amputation

Transfers

• Standing pivot transfer (for patients who can only partially participate)
• Backward forward transfer (bilateral amputee patients)
• Lateral transfer with skateboard transfer

• Standing pivot transfer

•  

• Standing pivot transfer

•  

• Backwards forwards transfer

•  

• Lateral transfer with a sliding board

•  

• Lateral transfer with a sliding board

[20][21]

Positioning

The main goal of positioning at any time is to prevent contractures in adjacent joints.

• For transtibial amputee, full knee extension and flexion are required, and
• For transfemoral amputee and knee disarticulation amputee – complete ROM of the hip, especially extension and adduction.

Full ROM will simplify prosthetic fitting and movement. [1]

Patients should be taught how to adjust their posture when sitting or standing on a hospital bed to prevent contractures.

• For transtibial: Avoid long poses with knees bent as much as possible (e.g. a mat under the knees)
• For transfemoral: Avoid positions in hip flexion and abduction (eg, a mat under the stump).

Transfemoral bed positioning [22]

Transtibial bed positioning [22]

Perform tibia in a wheelchair [22]

Wheelchair Management

• teach patients how to safely propel a wheelchair
• Remnant boar/knee extenders for patients with below-knee or knee amputations
• Seat belts may be required for patients with poor balance or height above the knee or with bilateral amputations
• Confused patients should be monitored [19]

using crutches or a walking frame to move

• Some patients may not want to use a wheelchair, especially young, agile and healthy patients [19]
• Make sure to explain the dangers of dependent position (sagging stump) to the patient early postoperatively as this may increase edema pain and healing time. [19]
• Use a gait belt with movement and transfer while using
• Wear a rigid removable dressing to protect the limb when moving the patient
• Give education on preventing falls

[23]

Resources

• Postoperative Physiotherapy at AustPAR
• Van Velzen AD Nederhand MJ Emmelot CH IJzerman MJ. Early management of transtibial amputee: retrospective analysis of early fit and elastic dressing. Prosthetics and Orthotics International. 2005 Apr;29(1):3-12. Available at: https://www.roessingh.nl/downloads/Early_treatment_of_trans-tibial_amputees_retrospective_analysis_of_early_fitting_and_elastic_bandaging.pdf
• Rigid Dressings from AustPAR
• Amputee Care – Use of post-operative rigid dressings for transtibial amputees. NSW Department of Health
• Rigid removable dressing. Amputee Information. Physiotherapy The Queen Elizabeth Hospital Woodville West SA