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8/10/2019 Stages of Care - Postoperative Management of the Lower Extremity Amputation _ American Academy of Orthotist

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12/16/2014 Stages of Care - Postoperative Management of the Lower Extremity Amputation | American Academy of Orthotists & Prosthetists

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Stages of Care - Postoperative Management of the Lower

Extremity Amputation

Stages of Care

Understanding the time frame of recovery from lower limb amputation is essential to the

design and implementation of any postoperative management strategy. Although today's

health care system has placed an emphasis on speed, the consensus committee participant

agreed that placing an emphasis on shortening the time of healing and recovery following

limb loss is not necessarily the wisest path.

Regardless of the etiology, the postoperative recovery period after the amputation of a lower

extremity typically is 12 to 18 months and simply cannot be rushed.1This 'recovery period'

includes activity recovery, reintegration, prosthetic management, and training. Some

members of the expert panel of the consensus committee felt that setting fast-paced and

often unrealistic goals can lead to a sense of failure in an individual who is actually

progressing normally.

The postoperative year-long continuum does not separate easily into "stages". However, an

attempt to define the stages of recovery has been made to facilitate discussion of how the

goals evolve throughout the rehabilitative process.

A. Preoperative Stage

The preoperative stage typically starts with the very difficult decision of whether to amputate

This stage also includes an assessment of the vascular status and decisions on attempts to

improve circulation. The difficult process of level selection, preoperative education, emotiona

support, physical therapy and conditioning, nutritional support, and pain management also a

occur in this stage of care.

B.Acute Hospital Postoperative Stage

The acute hospital postoperative stage is the time in the hospital after the amputation surgery

This hospital time typically ranges from 5 to 14 days.

C.Immediate Postacute Hospital Stage

In general, this stage begins with hospital discharge and extends 4, 6, or even 8 weeks after


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surgery. This is the time of recovery from surgery, a time of wound healing, and a time of ear

rehabilitation. Frequently, end points of this stage are characterized as the point of wound

healing and the point of being ready for prosthetic fitting. However, it should be noted that

healing of a residual limb is a continuous process, and the limb does not have a clear and

decisive point of "being healed." Furthermore, prosthetic readiness is a transition point that is

difficult to standardize and measure. Much of the current research comparing different

postoperative management strategies attempts to use these two elusive end points with

varying results.

D. Intermediate Recovery Stage

This is the time of transition from a postoperative strategy to the first formal prosthetic device

Historically, this device was called the "preparatory" prosthesis, but with the use of higher

technology earlier in the process, it is sometimes simply called the "first prosthesis." The term

"preparatory" has traditionally been linked to very basic prosthetic styles and components.The consensus committee participants felt that the historical interpretation of "preparatory

prosthesis" is no longer adequate.

It is during this stage that the most rapid changes in limb volume occur, due to the beginning

of ambulation and prosthetic use. The immediate recovery period begins with the healing of

the wound and usually extends 4 to 6 months from the healing date. Although difficult to

define, this stage ends with the relative stabilization of the residual limb size, as defined by

consistency of prosthetic fit for several months.

E.Transition to Stable Stage

This period is defined as a period of relative limb stabilization after the fourth stage when

rapid limb volume changes occurred. Although limb volume changes are not as drastic as in

this stage, the limb will continue to change to some degree, for a period of 12 to 18 months

after initial healing. Historically, this stage was marked as a transition from the "preparatory"

to the definitive prosthesis. Currently, with the use of higher technology and modular systems

in the previous stage (Intermediate Recovery Stage), this transition is no longer defined by a

change in the prosthesis, but rather a change from a rapidly changing limb to a slower

maturation of the limb. The prosthesis will still require occasional adjustments, and visits to

the prosthetist will remain relatively frequent until after the first year of prosthetic use. Modula

systems are appropriate and encouraged to enhance ease of socket replacement in this

stage.

In this phase the patient should move toward social reintegration and higher functional


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training and development as well as becoming more empowered and independent from his o

her health practitioner.

The fitting of the definitive prosthesis may certainly occur within this time period however,

limb stabilization must occur before definitive fitting. Residual limb volume must be stable so

the device can be used for an extended period of time. This extended period of time is

typically 2-5 years in adults and as long as 1 year in growing children.

Defining limb stability is very difficult. For most patients, the period of limb stabilization

requires at least 6 months of prosthetic use.

Clinical Concerns

The expert panel for this consensus committee identified fourteen clinical concerns in the

stages of recovery.

1. Determination of Amputation Level

2. Minimize systemic complications

3. Prevent contractures

4. Bed mobility and transfers

5. Pain management

6. Protect amputated limb from trauma

7. Fall prevention

8. Emotional care/education

9. Manage and teach about wound healing

10. Promote residual limb muscle activity

11. Early ambulation

12. Advanced ambulation

13. Control limb volume changes

14. Trunk and body motor control and stability

Each concern will take on a different level of importance at different stages of the healing

process. Since the goals of care change at each stage of rehabilitation, a table of clinical

concerns and treatment goals was established by the consensus committee for each stage.

(Table 1)There may be overlap between stages which may vary with individual differences.


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Table 1. Changing clinical concerns during the stages of recovery after a lower limb

amputation

These clinical concerns and treatment goals may be used by clinicians for development of

treatment protocols and guidelines within their communities. Each goal of the table is ranked

in relative importance with regard to the level of clinical concern at each stage of

rehabilitation. For example, the determination of amputation level is of concern at the

preoperative stage however, it is usually of little concern after the surgery. Conversely,

emotional care is of high clinical concern through most of the rehabilitation process, with a

slight drop off in the intermediate recovery stage and with a renewed concern at around 1

year after the amputation.

Although progression through these phases is largely individual, the time needed to progress

is reported consistently between 12 and 18 months. It is during this extended time that many

individuals still have significant changes in limb volume that must be considered and

managed. During this 12 to 18 month period, social reintegration, life planning, and goal

setting all progress as well. For pediatric amputees, the stages of recovery and the clinical

concerns are modified to take into account the developmental milestones of the growing chil


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Finally, in the later portions of the process come the mastery of prosthetic use and a desired

range of activities.

Physical Therapy and Prosthetic Management

Although the role of all team members is to assess, educate, and motivate the patient, the

role of two particular members of the team, the physical therapist and the prosthetist, during

this long period is often underestimated.

Physical therapytreatment continues throughout this entire period with specific

rehabilitation protocols designed to meet the specific needs of each amputee. Continua

reevaluation and updating of the amputee's program is essential to ensure that each

patient reaches his or her maximal activity level with a prosthesis.

Although the patient must be an active participant in his or her rehabilitative care,

the treatment guidelines and specific exercises are the therapist's responsibility

and an integral component of the continuum of care for the first 12 to 18 months.

Initialprosthetic managementafter amputation requires strategies different from thos

used during the period after residual limb stabilization.

During the initial time frame, the prosthetist is "chasing a moving target," as the

residual limb changes dramatically in volume and shape. - Therefore, the definitive

prosthesis should not be prescribed or fit until the limb has begun to stabilize andthe "moving target" has slowed considerably.

Stabilization is difficult to define and needs to be further researched. However,

when a patient has used a prosthesis full time for a period of at least 6 months an

when the limb volume has stabilized to a point that socket fit remains relatively

consistent for at least 2 to 3 weeks, a definitive prosthesis may be indicated.

Intermediate prosthetic managementconcentrates on edema reduction and to define

limb stabilization.

Additional studies need to be done to determine the most appropriate technique to

achieve this stabilization.

Little literature is available that attempts to define when adjustment of the current

socket may meet the needs of the patient versus when socket replacement is

required. Clearly, research is needed in this area.

Finally, it should be noted that a patient may return to work duringthis rehabilitative period,


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not just at the end of the process.

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Postoperative Management of the Lower Extremity Amputation

Table of Contents[2]

Wound Healing

Image courtesy of Robert Brown, CPO, FAAOP

Many lower limb amputations do not heal ideally in a primary fashion, and it is common that

small areas of the wound require secondary healing and a period of minor open wound care.

Revision surgery is also frequently required. 1

Wound healing problems are most commonly related to the injury, disease, vascularity,

tobacco use, and the nature of amputations themselves. Skin and wound problems are rarely

"caused" by a single factor and for many individuals are not preventable. It is uncommon for

lower limb amputations to heal primarily with no wound issues.

It should be noted that healing of an amputated limb is a continuous process, and there is no

a clear and decisive point of 'completed healing'. Therefore, 'time to heal' is nota precise

measure. However, documenting healing continues to be important for patient care and for

research.
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Determining healing time is prone to subjective interpretation of completion of:

epithelialization[3],

interpretation of the small open areas,

individual bias,

timing of the return to clinic visits, and

research savvy or knowledge of the prosthetic and rehabilitation team.

This is an area of significant controversy. Often the definition of "healed" and "healing" varies

from study to study. Thus, it is important that future studies clearly define how the "time to

heal" has been determined for each particular study.

'Time to heal' may always be difficult to standardize and to measure, and in reality cannotbe

determined accurately from simple retrospective review of a clinical chart. The Consensus

Committee defined categories of wound healing to aid the clinician and the researcher in

standardizing this often subjective area. In addition, the consensus committee made

recommendations on wound healing and weigh bearing activity.

The categories are:

A. Categories of Wound Healing

Category I. Primary Healing: heals without open areas, infection, or wound

complications. (Figures 1 & 2)


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Figure 1. Category I. The incision site is

healing with some small open areas that

should heal in time. No infection present.

Image courtesy of John Rheinstein, CO,

FAAOP & Lew Schon, MD.

Figure 2.Category I. The sutures are

removed from the incision site. Healing

appears to be proceeding with some small

open areas that should heal in time. No

infection present.

Image courtesy of John Rheinstein, CP,

FAAOP & Lew Schon, MD

Figure 3. Category II. A healing amputation with fluid and granulated tissue in areas where

the drainage tubes were removed.

Image courtesy of John Rheinstein, CP, FAAOP & Lew Schon, MD

Category II. Secondary Healing: small open areas that can be managed and

ultimately heal with dressing strategies and wound care. Additional

surgery is not required. (Figure 3) This can occasionally be the

original plan with some portion of the amputation intentionally left

open. (Figure 4)


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Figure 4. Open amputation. A, severely abscessed right foot of a 43-year-old insulin

dependent diabetic prior to supramalleolar amputation and wide debridement of ascendinginfection of all crural compartments. B, the anterior compartment wound at 17 days

demonstrates granulation at time of partial closure. C, lateral view of distal partial closure.

Only enough bone to effect myodesis closure was removed. D, the same residual limb 3

months following initial open amputation the limb is ready for prosthetic fitting.

Image courtesy of: 18-A Transtibial Amputation: Surgical Procedures and Immediate

Postsurgical Management. In: Bowker JH, Michael JW, eds.Atlas of Limb Prosthetics:

Surgical, Prosthetic, and Rehabilitation Principles, 2nd edition, Rosemont, IL:AAOS, 2002.Image downloaded from the O & P Virtual Library, www.oandplibrary.org[4] Accessed June

2008.

Category III. Requires minor surgical revision of skinand/or subcutaneous
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tissue but no muscle or bone. (Figure 5)

Figure 5.Category III. An example of a wound with areas of necrotic skin. This limb will

require minor revision surgery to the wound site and more aggressive treatment protocols toprevent a major revision.

Image courtesy of NUPOC

Category IV. Requires major surgical revisioninvolving muscle and/or bone

however, the wound heals at initial amputation 'level'. For example, a

mid- length transtibial amputation that is revised and eventually heals

at a shorter transtibial level. (Figure 6)

Category V. Requires revision to a higher amputation level. For example, a

Symes amputation that must be revised to either a knee

disarticulation or a transfemoral amputation. (Figure 7)


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Figure 7Category IV possible Category V. If infection has reached the bone and

oseteomyelitis has set in then revision of the skin, muscle and bone will be required to a

more proximal amputation level.

Image downloaded from the O & P Virtual Library, www.oandplibrary.org[5] Accessed June

2008.

For more information regarding wound healing[6], visit the following links:

B. Wounds and Weight Bearing Activity

Image courtesy of John Rheinstein, CP, FAAOP & Lew Schon, MD

Presence of an open wound or the presence of sutures does not necessarily preclude weigh

bearing. The institution of activity, or even continuation of, can be helpful in controlling edema

and facilitating healing. This has been demonstrated in the literature since the early 1920s. 2

Although initial instincts are to avoid prosthetic use and weight bearing whenever there is a

wound or skin problem, this may not be appropriate in some cases. While a treating physicia

must examine the wound and the prosthetist must examine the device for evidence of device

specific pressure points, the literature actually supports weight bearing and continued activity

in certain situations to enhance wound healing. 3,4However, more research needs to be

conducted to elucidate the most appropriate duration and amount of weight bearing to
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enhance wound healing.

Good direct communication about healing issues and wounds among providers and educatio

of the patient are vital. Repeated wound assessment and modification of the treatment plan

as needed are important. Decisions regarding weight-bearing activity should be made based

on:

1. the progression of the particular wound,

2. the lack of progression, or

3. the worsening wound appearance.

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Postoperative Management of the Lower Extremity Amputation

Table of Contents[8]

References

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2. ^Table of Contents (www.oandp.org)

3. ^View Expanded Content (www.oandp.org)

4. ^www.oandplibrary.org (www.oandplibrary.org)

5. ^www.oandplibrary.org (www.oandplibrary.org)

6. ^View Expanded Content (www.oandp.org)

7. ^Close Window (www.oandp.org)

8. ^Table of Contents (www.oandp.org)

Excerpted from Stages of Care - Postoperative Management of the Lower Extremity Amputation | American Academy of Orthotis

& Prosthetis

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