STUMP CARE, PHANTOM LIMB PAIN , GAIT TRAINING IN LOWER LIMB

HARSHITA YADAV M.P.T (ORTHOPAEDICS)

AMPUTATION

• Derived from the Latin amputare. • "to cut away", from ambi- ("about",

"around") and putare ("to prune").

• Amputation is the complete removal of an injured or deformed body part.

• The English word "amputation" was first applied to surgery in the 17th century.

Amputation is the calculated surgical removal of all or part of an extremity when its blood supply is irreversibly compromised by disease or severe injury.

(Medical Disability guidelines)

The national center for Health Statistics estimated that more than 300,000 patients with amputations live in the US.

DEFINATION

INCIDENCE

( Campbell’ s operative orthopaedics , vol 1, 7th ed.)

The reported annual incidence of LLA related to peripheral vascular disease has ranged from approximately 20 to 35 per 100,000 inhabitants.

It has been reported that one in four diabetic individuals develops peripheral vascular disease that, when severe, may require amputation .

(Incidence of Lower-Limb Amputation in the Diabetic and

Nondiabetic General Population; Diabetes Care 32:275–280, 2009)

Amputation can be regarded as a treatment and not tragedy

Indications :-

1. Dead ( or dying ) limb

Peripheral vascular disease ( 90% ) Sever trauma Burns Frostbite

2. Dangerous limb

Malignant tumors Lethal sepsis Crush injury leading to Crush syndrome

3. Damn nuisance

Retaning the limb is more worse than having no limb at all …. Because of :-

Pain Gross malformation Recurrent sepsis Sever loss of function

CAUSES

o CONGENITAL ACQUIRED

- Vascular

- Trauma

- Infection

- Neoplasm

- Iatrogenic - - Neuropthic

(Rehabilitation S Sunder 3rd ed.)

CONGENIAL ANOMALY

PERIPHERAL VASCULAR DISEASE

TRAUMA (severe tissue damage) – traumatic amputation

MALIGNANT TUMOUR

SCLERODERMA

DIABETES CRUSH INJURY

BURNS FROTBITE

90 % amputation – peripheral vascular disease Young patient – trauma/ malignancy Absolute indication – irreversible ischaemia:

disease or trauma ( Campbell’ s operative orthopaedics , vol 1, 7th ed.)

70% of lower-extremity amputations result from complications associated with diabetes mellitus and peripheral vascular occlusive disease.

Peripheral vascular compromise, resulting from diabetes mellitus, leads to multiple health problems, including poor ability to heal wounds, infections, ischemia and neuropathy .Due to these factors, people who have diabetes are 15 times more likely to have an amputation.

(The Influence of Lower-Extremity Muscle Force on Gait Characteristics in Individuals With Below-Knee Amputations Secondary to Vascular Disease , APTA ; Vol – 76 )

PRINCIPLES

GENERAL SURGICALPRINCIPLES PRINCIPAL

(Rehabilitation S Sunder 3rd ed.)

GENERAL PRINCIPLES To save as much limb as possible while

providing a residual limb that is able to tolerate the stress of the prosthesis and return to mobility .

SURGICAL PRINCIPLES

The use of tourniquet is advised to obtain a bloodless field – except in ischemic conditions.

Level of amputation – effort should be made to preserve all possible limb length, keeping in mind the prosthesis to be fit.

(Rehabilitation S Sunder 3rd ed.)

Skin flaps – skin should be mobile , sensation intact , and without adherent scars.

Muscles are divided 3 to 5 cm distal to the level of bone resection.

Nerves are gently pulled and cut cleanly so

that they retract well proximal to the bone level. This reduces complication of neuroma.

(Rehabilitation S Sunder 3rd ed.)

Several studies have suggested guidelines to help ,to decide which limb is salvageable. Most of these studies have concentrated on severe injuries of the lower extremity.

Most authors would agree with Lange’s absolute indications for amputations of type3-C open tibial #, which include complete distruption of the tibial nerve or a crush injury with warm ischemia ,time of more than 6 hrs.

Lange’s relative indications for primary amputation include:

* Severe associated injuries

* Severe ipsilateral foot injuries

*Anticipated protracted course to obtain soft- tissue coverage and tibial reconstruction

DESIGN MAKING FOR THE SALVAGEABLE LIMB

Other authors have attempted to remove subjective decision making process.

To predict which limbs will be salvalgeable, available scoring systems include :

• the predictive salvage index,• the limb injury score, • the limb salvage index, • the mangled extremity syndrome index, and• the mangled extremity severity score.

Of these , it was found that the mangled extremity severity score was to be most useful.

( Campbell’ s operative orthopaedics , vol 1, 7th ed.)

( Campbell’ s operative orthopaedics , vol 1, 7th ed.)

1. MYODESIS -

o Muscles & fasciae are sutured directly to the distal residual bone through drill holes.

o Muscles inserted function better , resulting in good prosthetic control.

o Procedure compromises blood supply to the muscles & hence is contraindicated in patients with severe peripheral vascular disease.

o Sometimes myodesis fails even with best care.

(Rehabilitation S Sunder 3rd ed.)

SURGICAL PROCEDURE

2. MYOPLASTY –o Procedure require surgeon to suture the opposing muscles in

the residual limb to each other & to the periosteum or to the distal end of the cut bone.

o Muscles must be stretched enough so that they control the residual limb.

o Muscles sutured to each other provide distal soft-tissue padding over the residual bone.

o Sometimes a painful bursa develops between the soft tissues & underlying bone and some of these bursa can become infected & painful.

3. OSTEOMYODESIS –o Similar to myodesis but the periosteum is stripped. This

enables bone growth in that area.

(Rehabilitation S Sunder 3rd ed.)

TYPES OF AMPUTATION(classified according to the surgical technique or the emergency of situation)

1.PROVISIONALUsed when primary healing is unlikely or delayed because of infection, ischemia, or inadequate wound debridement. It is done as an emergency procedure , to save the life of the patient.

2. DEFINITIVEUsed after provisional amputation as an elective surgery. In this, level is well- defined & thought out, with the ultimate prosthesis kept in mind.

(Rehabilitation S Sunder 3rd ed.)

3. ACCORDING TO THE ANATOMICAL LEVEL

Depending on whether the amputation is through the joint or the bone, these may be defined as:

Disarticulation: amputation through joint

Through the shaft of a long bone

(Rehabilitation S Sunder 3rd ed.)

LEVEL OF AMPUTATION IN LOWER LIMB

HEMICORPORETOMY Amputation both lower limbs & pelvis below L4- L5 level

HEMIPELVECTOMY Resection of lower half of the pelvis

(Physical rehabilitation;Susan B O’ Sullivan; 5th )

HIP DISARTICULATIONAmputation through hip joint ; pelvis intact

SHORT TRANSFEMORAL(Above knee)Less than 35% femoral length

(Physical rehabilitation; Susan B O’ Sullivan; 5th )

TRANSFEMORAL(above knee)Between 35% & 60% femoral length

LONG TRANSFEMORAL(above knee)More than 60% femoral length

KNEE DISARTICULATION Amputation through the knee joint; femur intact

SHORT TIBIAL(below knee)Less than 20% tibial length

TRANSTIBIAL(below knee)Between 20 -50% of tibial length

LONG TRANSTIBIAL (below knee)More than 50% tibial

SYME’S AMPUTATIONAnkle disarticulation with attachment of heel pad to distal end of tibia. Many include removal of malleoli & distal tibia/ fibular flares

TRANSMETATARSALAmputation through mid section of all metatarsals

PARTIAL FOOT/ RAY RESECTIONResection of the 3rd, 4th , 5th metatarsals and digits

TOE DISARTICULATIONDisarticulation at the metatarsal phalangeal joint .

PARTIAL TOEExcision of any part of one or more toes

Closed amputation one in which flaps are made from the skin and subcutaneous tissue and sutured over the end of the bone.

Amputation in contiguity amputation at a joint.

Amputation in continuity amputation of a limb elsewhere than at a joint.

Double-flap amputation one in which two flaps are formed.

Elliptic amputation one in which the cut has an elliptical outline.

Teale's amputation  amputation with short and long rectangular flaps

Gritti-Stokes amputation  amputation of the leg through the knee, using an oval anterior flap.

Guillotine amputation  one performed rapidly by a circular sweep of the knife and a cut of the saw, the entire cross-section being left open for dressing.

Racket amputation  one in which there is a single longitudinal incision continuous below with a spiral incision on either side of the limb.

Boyd’s amputation at the ankle with removal of the talus and fusion of tibia & calcaneous

Spontaneous amputation  loss of a part without surgical intervention, as in diabetes mellitus.

Subperiosteal amputation  one in which the cut end of the bone is covered by periosteal flaps.

Chopart's amputation  amputation of the foot by a midtarsal disarticulation.

Lisfranc's amputation  amputation of the foot between the metatarsus and tarsus.

Approximately 60,000 transtibial and transfemoral amputations are performed each year in the United States alone.

(Gait Training With Virtual Reality–Based Real-Time Feedback:Improving Gait Performance Following Transfemoral Amputation; September 2011; Volume 91 Number 9 Physical Therapy)

Multiple studies, have documented the increased rehabilitation rate in BKA vs AKA patients, with more than 65% of BKA patients ambulating with prosthesis. In contrast, less than one third of AKA patients are likely to rehabilitate with the use of a prosthesis.

(Major Lower Extremity Amputation; Arch Surg. 2004;139:395-399)

Likely, due to the significant comorbidities of patients undergoing amputation for ischemic disease, perioperative mortality rates range from 0.9% to 14.1% for BKA patients and are significantly worse for AKA patients at 2.8% to 35%.

(Major Lower Extremity Amputation; Arch Surg. 2004;139:395-399)

POST – OPERATIVE DRESSINGS

DRESSINGS

RIGID DRESSINGS

SEMI-RIGIDDRESSINGS

SOFT DRESSINGS

SHRINKERS ELASTIC WRAPS

REMOVAL RIGID DRESSINGS

NON REMOVAL RIGID DRESSINGS

SEMI-RIGID DRESSINGS

ELASTIC SOFT DRESSINGS

SHRINKERS

COMPLICATIONSCOMPLICATIONS

HAEMATOMA

DEHISCENCE/WOUND BREAKDOWN

PROBLEMS ASSOCIATED WITH THE SURROUNDING SKIN

BONE EROSION/OSTEOMYELITIS

INFECTIONTISSUE NECROSIS

STUMP OEDEMA.

PAIN

(Wound healing complications associated with lower limb amputation 29-Sep-2006 15:28:16 BST)

TISSUE NECROSIS DEVELOPING ON A STUMP WOUND CAUSING WOUND BREAKDOWN.

EXTENSIVE TISSUE NECROSIS TO A STUMP EXTENDING BELOW THE SUTURE LINE CHARACTERISED BY DISCOLORED, CYANOSED

BLISTERINGCONTACT DERMATITIS TO THE DISTAL END OF A STUMP CAUSED BY THE APPLICATION OF TAPE.

(Wound healing complications associated with lower limb amputation 29-Sep-2006 15:28:16 BST)

A DEHISCED ABOVE-KNEE AMPUTATION WOUND EXPOSING THE FEMUR.

STUMP SINUS MASKING UNDERLYING OSTEOMYELITIS.

(Wound healing complications associated with lower limb amputation 29-Sep-2006 15:28:16 BST)

Classified as:Classified as:

PREPROSTHETIC

1. Delayed healing2. Skin adherence to

bone of residual limb3. Problems in shaping

of residual limb4. Contractures5. Chronic wound sinus

POSTPROSTHETIC

1. Painful residual limb2. Adherence of skin to

bone3. Insensitive skin4. Poor Fit5. Boney overgrowth in

children6. Degenerative arthritis7. Fractures

(Atlas of Limb Prosthetics: Surgical, Prosthetic, and Rehabilitation Principles)

Knee flexion contracture that occurred from a failure to apply postoperative rigid dressing following transtibial amputation.

Appositional overgrowth of the humerus in an adolescent transhumeral amputee.

(Atlas of Limb Prosthetics: Surgical, Prosthetic, and Rehabilitation Principles)

The phantom is the sensation of the limb that is no longer there. The phantom, which usually occurs initially immediately after surgery, is often described as a tingling, burning, itching or pressure, sensation, sometimes a numbness.

Phantom sensation may be painless although, most people find it uncomfortable & often report it as pain; it usually does not interfere with prosthetic rehabilitation.

(Physical rehabilitation;Susan B O’ Sullivan; 5th )

PHANTOM LIMB PAIN

Phantom pain and sensations are defined as perceptions ranging from slight tingling to sharp, throbbing pain or aching that patients perceive relating to an extremity or an organ that is physically no longer a part of the body.

• It has been reported in various trials that the estimated prevalence of phantom pain varies from 49% to 83%.

(A Retrospective Trial Comparing the Effects ofDifferent Anesthetic Techniques on Phantom Pain After Lower Limb Amputation; 2011 Elsevier HS Journals)

Amputees can experience two different types of pain: incisional stump pain and phantom pain.

Stump pain is localised to the area immediately around the stump and the amputation scar and is described by patients as 'pressing', 'throbbing', 'burning' and 'squeezing'

(Wound healing complications associated with lower limb amputation 29-Sep-2006 15:28:16 BST)

Phantom pain is a common problem, affecting between 8% to 10% of patients and is usually reported during the immediate postoperative period but can persist for up to two years. In some cases, phantom pain can be a lifelong experience.

It is literally pain experienced in the limb that has been amputated, and is often described as a crushing, tearing pain.

(Wound healing complications associated with lower limb amputation 29-Sep-2006 15:28:16 BST)

The pain may be localized or diffuse; it may be continous or intermittent & triggered by some external stimuli.

(Physical rehabilitation;Susan B O’ Sullivan; 5th )

The neuromatrix is defined as a neuronal organization that is genetically determined within individuals and modified by sensory experiences. According to this theory, abnormal impulses that reach the neuromatrix after an extremity amputation change the neuromatrix pattern, and this causes conversion of normal input to pain sensations, in other words, causes phantom pain.

(A Retrospective Trial Comparing the Effects ofDifferent Anesthetic Techniques on Phantom Pain After Lower Limb Amputation; 2011 Elsevier HS Journals)

The interference of normal impulse traffic to the brain and excessive impulse discharge from damaged neurons after amputation are believed to be responsible for occurrence of phantom pain. Additionally, somatosensory pain memory can awaken after amputation, thus leading to phantom pain.

(A Retrospective Trial Comparing the Effects ofDifferent Anesthetic Techniques on Phantom Pain After Lower Limb Amputation; 2011 Elsevier HS Journals)

In amputees with phantom limb pain, regional anaesthesia at the stump causes both rapid reduction in cortical reorganisation & elimination of phantom limb pain, although phantom limb pain returns as anaesthesia subsides.

(Is sucessful rehabilitation of complex regional pain syndrome due to sustained attention to the affected limb? A randomised clinical trail; G. Lorimer Mosely* ;pain;2004;11,024)

Non invasive treatments such as US, icing, TENS, or massage have been used with varying success. Mild non-narcotic analgesics have been of limited value; biofeedback, guided imagery, psychotherapy, nerve blocks, & dorsal rhyzotomies have been used with inconsistent results.

(Physical rehabilitation;Susan B O’ Sullivan; 5th )

MANAGEMENT FOR PHANTOM LIMB PAIN

Pain relief associated with mirror therapy, may be due to the activation of mirror neurons in the hemisphere of the brain that is contralateral to the amputated limb. These neurons fire, when a person either performs an action or observes another person performing an action. Therefore , mirror therapy may be helpful in alleviating phantom pain in an amputated lower limb.

(Mirror Therapy for Phantom Limb Pain; E NGL J MED; 357;21;2007)

PHYSIOTHERAPEUTIC MANAGEMENT

PRE-OPERATIVE• ASSESSMENT• STRENGTH TRAINING

POST-OPERATIVE

PRE-PROSTHETIC• ASSESSMENT• STUMP

STRENGTHENING• STUMP TRAINING FOR

PROSTHESIS

POST-PROSTHETIC• GAIT TRAINING• STUMP HANDLING

PRE-OPERATIVE MANAGEMENT

Training involves:• Breathing exercises• Strengthening exercises• Mobilization exercises• Bed mobility• Transfers • Stabilization exercises• Wheelchair training

Strengthening exercisesBed mobility and transfers

Wheelchair training

POST-OPERATIVE MANAGEMENT The aims of treatment are:

• Prevention of joint contracture• To strengthen and mobilize unaffected leg• To strengthen and co-ordinate the muscles controlling

the stump• To strengthen and mobilize the trunk and retrain

balance• To teach the patient to regain independence in

functional activities• To control oedema of the stump and commence early

ambulation• Re-education of sensation in healed stump• Successful discharge into community

PRE-PROSTHETIC

Cardiac precaution

Oedema control can be done by following methods:

• Elevation and exercises• Bandaging• Shrinker socks• Rigid dressing• Intermittent pressure machines• PPAM aid: pneumatic post

amputation mobility aid

Care of the Stump

– Keep the stump clean, dry, and free

from infection at all times.

– If fitted with a prosthesis, you should remove it before going to sleep.

– Inspect and wash the stump with mild soap and warm water every night, then dry thoroughly and apply talcum powder.

– Do not use the prosthesis until the skin has healed.

– The stump sock should be changed daily, and the inside of the socket may be cleaned with mild soap.

RESUDIAL LIMB WRAPPING Eary wrapping provides a no. of positive benefits:o Decrease odema & venous stasis

o Assist in shaping

oHelp in counteract contracture oProvide skin protection oReduce redundant tissue problems

o Reduce phantom limb sensation and discomfort oDesensitize the residual limb with local pain

Residual limb wrapping

Post-operative stump training

• Exercise• Massage• Pressure• Mobilization• Strengthening

PPAM aid for pressure tolerance training

Short arc quadriceps

Straight Leg Raise

Ankle Pumps

Side Lying Hip Abduction - Modified

Side Lying Hip Abduction - Advanced

Prone Hip Extension

Prone Hip Extension (Sound Limb)

Prone Adductor Squeeze

Prone Knee Flexion

Push-ups

Quadruped Leg Lift

Abdominal Curl-up

Bosu Head Twists

Bosu Ball Exercises

POST-PROSTHETIC

Prosthetics

It is a replacement of substitution of a missing or a diseased part

Types of Prosthesis

BELOW KNEEKNEE

DISARTICULATION ABOVE KNEEHIP

DISARTICULATION

PROSTHETICSLOWER EXTREMITY

Ideal prosthesis

1. Fits comfortably 2. Function well 3. Looks presentable4. Fit as soon after the operation

Classification

Endoprosthesis- implants used in Orthopaedic surgery eg; austin moore Prosthesis

Exoprosthesis-external replacement for a lost part of the limb

TYPES

Temporary – Used following amputationtill paient is fitted with permanent prosthesis eg;pylon

Permanent prosthesis

Lower Limb Prosthesis

Types of lower limbs prosthesis :

Types of L.L. prostheses depend on different stages after amputation.

There are three types:

- Immediate post- operative prosthesis- Temporary prosthesis- Definitive prosthesis

DONNING & DOFFING

Center of gravity

schnall5_512K.mp4