1.2 Amputee Rehabilitation

• Background

  • 4 Singaporeans lose a limb or appendage due to diabetic-related complications a day
  • DM patients has 10 times higher risk for lower extremity amputation compared with the general population
  • Mortality rate at 1 year was 30.7%
• A multidisciplinary team approach and multifactorial treatment of foot ulcers have been reported to reduce the amputation rate by more than 50%.
• Causes of Amputation

  • Vascular Disease - peripheral vascular diseases, diabetes mellitus
  • Trauma - fractures
  • Infection - treatment of sepsis with vasoconstrictor agents
  • Malignancy - tumour
  • Congenital - failure of partial or complete formation of a portion of limb
  • Others - burn, frostbite
• Amputations

  • Trans - amputation across the axis of a long bone
  • Disarticulation - amputation between long bones, through center of joint
  • Partial - amputation of foot distal to ankle joint and of hand distal to wrist joint
  • Sound Limb - intact "healthy" limb
  • Stump - extremity of a limb left after amputation
• Major Lower Limb Amputations

  • Hemipelvectomy - removal of any part of ilium, ischium or pubis
  • Hip Disarticulation - removal of entire femur
  • Transfemoral - above knee amputation (AKA)
  • Knee Disarticulation - through knee amputation (TKA)
  • Transtibial - below knee amputation (BKA)
  • Van Ness Rotationplasty - removal of limb with tumour, distal limb is reattaches to proximal limb, foot faces backwards
• Minor Lower Limb Amputations

  1. Toe/Ray
  2. Metatarsal Phalangeal
  3. Transmetatarsal
  4. Lisfranc's
  5. Chopart's
  6. Pirogoff
  7. Syme's

  
• Surgical Principles

  • Skin - greatest skin length possible for muscle coverage and tension-free closure
  • Bone - bony prominences around disarticulations removed with a saw and filed smooth
  • Nerves - transacted under tension, cut nerves placed more proximal in scar-free environment to prevent neuroma
  • Vessels - Larger arteries and veins are dissected and separately ligated to prevent development of fistulas and aneurysms
  • Muscle - myodesis (muscles and fascias are sutured directly to distal residual bone through drill holes), myoplasty (suturing muscle to periosteum or fascia of opposing muscle)
• Common Incision Lines

  • Long posterior flap
  • Fishmouth flap
  • Sagittal flap
  • Skewed flap
• Common Terminologies

  • Casting - act of measuring size and mould shape of a stump, mould will be used to fabricate prosthesis
  • Fitting - trying on prosthesis and making adjustments
  • Delivery - allowing patient to bring prosthesis home to practise or for use in inpatient settings
• AMPutee Single Item Mobility Measure

  • 7 level classification of clinically meaningful descriptors
  • For dysvascular amputee
  • Strong criteria and construct validity

  
• K Level Classification

  • 5 level classification system
  • Describes functional abilities
  • Potential to achieve defined functional status

  
• Amputee Mobility Predictor

  • Determine K level classification
  • Determine which activity to be addressed
  • Predict 6min walk distance
  • Measures change over time
  • AMPnoPRO/AMPPRO
• Timed Up and Go Test

  • For analysis of combination of functional task (standing, walking, turning)
  • Non-amputees (>13.5s) and amputees (>19s) identify multiple fallers
  • MCID: 3.6s, sigificant ceiling effect
• 10m Walk Test

  • For measurement of gait speed
  • Speed require to cross most roads in Singapore: 0.76m/s
  • 13s to be able to cross roads safely
• 2/6 Minute Walk Test

  • For measurement of exercise capacity
  • MCID: 45m (6min), 34.5m (2min)
  • Predicting 6MWT from 2MWT: 6MWT=3.1(2MWT)-54.4
• Houghton Scale

  • Classify walking ability, assess rehab outcome, patient's perspectives
  • >8: independent community, 6-8: household and limited community, <6: limited household
• Functional Independence Measure (FIM)

  • Assess and grade functional status based on the level of assistance
  • Consist of motor and cognition subscale
  • Each item scored on a 7 point ordinal scale (1-7)
  • Higher score = independence
• Aims

  • Immediate post-op phase - prevent complications
  • Pre-prosthetic phase - ensure readiness for prosthetic casting
  • Prosthetic phase - optimize gait and functional use of prosthesis, integrate use of prosthesis as part of daily life
  • Re-integration phase - maximise quality of life
• Amputees with co-morbidities of diabetes mellitus or peripheral vascular diseases have a slower healing rate.
• Age alone does not mean poor prognosis of prosthetic use.
• Pre-op walking status is a predictor of walking ability.
• Pre-prosthetic ADL training has a clincally meaningful effect on functional independence in bathing and showering, toileting, bed-chair transfers and dressings.
• Dependency for self-care is a negative predictor for walking ability.
• Good Predictors of Prosthetic Outcomes

  • Lower level of amputation
  • Lower level of co-morbidities
  • Lower level of pain
  • Good physical status
  • Good cognition
  • Good psychological status
  • Timely modification of home environment
  • Good support and motivation
• Stump Oedema Management

  • Positioning
  • Rigid Removable Dressing (RRD) - accelerates healing, reduce edema and pain, protects stump, increased success with prosthesis
  • Bandaging - not recommended as it is difficult to do it correctly
  • Shrinkers - recommended to use as soon as possible after operation
• Assessment for Remaining Limb

  • Circulatory status: capillary return time, pulses, temperature, colour
  • Sensation: light touch, proprioception
  • Deformity: Charcot's neuropathy, calluses, claw foot, hammer toe
• Cardiopulmonary Goals

  • Improve cardiopulmonary fitness
  • Increase efficiency of ADLs and ambulation
• Musculoskeletal Treatment

  • Muscle Length: 0deg knee extension, 10deg hip extension
  • Muscle Strength: hip abductors, hip extensors, knee extensors, upper limb strengthening, advance strengthening
• Balance Goal

  • Single leg balance > 10-30s without support
• Criteria for Casting

  • Stump - wound healed, minimal edema
  • Sound Limb - no wounds on plantar surface, allowed weight bearing
  • Physical Function - stand >30s, ambulate 2 rounds with PPAM
  • Funding - self pay, approved funding
• Common Transtibial Gait Deviations

  • Excessive knee flexion from heel strike to midstance
  • Knee hyperextension from heel strike to midstance
  • Unequal step length
  • Excessive valgus/varus moment
  • Drop off
  • Rotation of foot
  • Lateral trunk bending
  • Pistoning
• Common Transfemoral Gait Deviations

  • Abducted
  • Lateral trunk flexed in stance towards prosthetic side
  • Circumduction
  • Vaulting
  • Medial/Lateral whip
  • Lumbar hyperlordosis
• Delivery

  1. Don/Doff
  2. Educated
  3. Alignment
  4. Comfort, no pain
• Running Rehabilitation

  • Prosthetic trust
  • Backward extension
  • Sound limb stride
  • Stride symmetry
  • Arm swing