Case study

The benefits resulting from immediate postsurgical fittings and subsequent ambulation of patients with lower extremity amputations are many. Utilization of this procedure by experienced surgeons and physical therapists working with improvised pros­ thetic materials in a minimally equipped hospital is reported. The authors recommend use of adap­ tive procedures for clinicians in hospitals lacking a staff prosthetist and standard rehabilitation equipment.

Rehabilitation of the Patient with a

Postsurgical Lower Extremity Amputation

T,

STEVEN L. WOLF, M.S. and JOSEPH K. REED, JR., B.S.

he surgical principles and benefits derived from immediate postoperative fittings and ambulation of patients with lower extremity amputations have been described at length.1 - 3 Among these benefits are the pro­ duction of functionally active stump muscula­ ture with intact proprioception, return of normal arterial and venous circulation, enclosure of the bone end with muscle thus eliminating distal pain from protruding bone, maintenance of smooth skin on the stump, a rounded cylindrical stump, decreased hospitalization for the patient, a more immediate and active role played by the patient in his own rehabilitation, improve­ ment of the patient's morale and motivation, elimination of phantom pain, and decreased edema with accompanying promotion of heal­ ing.

Mr. Wolf was Instructor of Anatomy at Sargent College of Allied Health Professions, Boston University, at the time this paper was prepared. He is currently a doctoral student in anatomy at Emory University, Atlanta, Georgia 30322.

Mr. Reed is working with the prosthetic-orthotic pro­ gram at the U.S. Public Health Service Hospital in Car- ville, Louisiana 70721.

This paper is adapted from a presentation at the U. S. Public Health Service Clinical Society Meeting, San Fran­ cisco, California, March 1968.

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Fig. 1. Anterior view of pylon using the axillary border of a crutch for weight bearing.

which was still shorter than the time required by some patients who have undergone a con­ ventional amputation procedure and subsequent rehabilitation.5-9 Because of inadequate reha­ bilitative supplies and minimal availability of a prosthetist, the authors were given the op­ portunity of improvising postoperative materials and altering rehabilitative procedures.

PREOPERATIVE TREATMENT

Patients treated with the immediate fitting procedure were fitted with standard crutches, taught to rise and sit as well as ambulate, using a non-weight-bearing gait. Active assistive range-of-motion exercises for the affected lower extremity were begun and the patients were in­ structed in active range-of-motion exercise to knees and hips whenever possible. All patients were instructed to perform isometric quadriceps exercises. Exercises to prevent flexion contrac­ tures at the hip and knee joints were instituted at least one week prior to surgery. Strengthen­ ing exercises for the trunk and upper extremi­ ties were added as tolerated. Patients with emphysema or bronchitis were taught deep breathing exercises and postural drainage.

The benefits resulting from this surgical and rehabilitative procedure were verified in six amputations performed on five male patients at the U. S. Public Health Service Hospital, Boston, Massachusetts. The patient age range was sixty-one to seventy-three years with a mean age of sixty-seven. Two patients with peripheral vascular disease had amputations above the knee (AK); the remaining three had peripheral vascular disease with accompanying diabetes mellitus and underwent amputations below the knee (BK). One BK stump became infected and gangrenous necessitating an AK amputation. One patient expired from unre­ lated medical complications. The average post­ operative hospitalization period was three and one-half months. This time period is long when compared with other studies.4 Delay and altera­ tions in the final prosthesis, the unavailability of a prosthetist, and unrelated medical prob­ lems lengthened the hospitalization period,

POSTOPERATIVE PROCEDURE

Because the commonly used adjustable py­ lons were not available at this hospital, a more primitive pylon for immediate postoperative ambulation was improvised. The pylon con­ sisted of a crutch incorporated at the medial and lateral aspects of the plaster total contact socket. For two patients the axillary border of a crutch was used as a weight-bearing base, with the medial aspect excised to prevent trip­ ping of the unaffected extremity during its swing phase (Fig. 1). Two patients ambulated with a pylon using the crutch tip as a walking base (Fig. 2). One patient with a BK amputation used a patellar-tendon-bearing (PTB) prosthe­ sis fastened to the plaster total contact socket as a pylon (Fig. 3).

Upon returning from the operating room, each patient was placed supine for bed rest. All patients were able to achieve a standing position within twenty-four hours following

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surgery. From that time to forty-eight hours postoperatively the amputated limb stumps re­ mained elevated. Because of pain and limited mental alertness, initiation of the ambulatory period varied from twenty-four to seventy-two hours postoperatively. The first time the pa­ tients came to the physical therapy department they were placed in the parallel bars for stand­ ing balance and weight bearing as tolerated. Secondly, a three-point gait and elevation of the pelvis on the side of the amputated limb

were emphasized. For the first postoperative

week, the patients ambulated in the parallel

bars, gradually adding weight to their pylons during increased walking distances. Each pa­ tient walked at least twice a day. Such activi­

ties as weight transfer, balance, and abduction at the hip joints were taught to the patients.

Progressive resistive exercises were initiated for the unaffected limbs, and the patients were

taught to transfer independently from the wheel­

chair or bed to the standing position. Through­ out the rehabilitative course, each patient did progressive resistive or isometric exercises for the hip joint of the amputated extremity. Pa­ tients were also instructed to perform strength­ ening exercises for trunk musculature.

On the fourteenth postoperative day, the total contact socket, the temporary pylon, and stump sutures were removed. A second total contact socket with the improvised pylon was applied in a manner identical to that of the postopera­ tive procedure. When the prosthetist was avail­ able, an initial fitting for the final prosthesis was made. Often the inaccessibility of a pros­ thetist meant a delay up to four weeks before a patient could receive an initial fitting.

By the end of the second week, the patients had progressed to the use of an axillary walker; by the fourth postoperative week standard crutches could be used. At no time did any patient report phantom limb sensation. When the final prosthesis arrived (in some instances two months following surgery), instruction in its use and in activities of daily living were given until the patient had achieved maximal inde­ pendence. This time period did not exceed three weeks. Three patients with unilateral lower extremity amputations ambulated inde­ pendently with standard crutches or a cane when discharged. The patient with bilateral

Volume 50 / Number 12, December 1970

Fig. 2. Anterior view of pylon using the crutch tip as a length-adjustable base of support.

lower extremity amputations was ambulating in­ dependently with a walker or Canadian crutches when discharged.

DISCUSSION

Contraindications to conventional amputa­ tions and amputations using myoplastic pro­ cedures have been thoroughly discussed.1 0 - 1 5 In addition to emphasizing the importance of good muscle status, Vitali has recommended that the therapist recognize mental impairment or loss of ability to learn, for these factors may con- traindicate the surgical procedure.1 6 Primary contraindications are lack of patient motivation and the presence of contractures. Patients who might have appeared lethargic and indifferent prior to surgery at this hospital, however,

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Fig. 3. Anterior view of patient with bilateral lower extremity amputations using a PTB pros­ thesis as a pylon for right lower extremity.

seemed to have been impressed with the sur­ gical results and, consequently, have come to the therapist with a feeling of renewed hope and vitality. This patient attitude should be nurtured by the physical therapist to attain maximum cooperation from the patient through­ out the rehabilitative period. Contractures may be present prior to surgery or may develop post­ operatively. To prevent flexion contractures at the joints, splinting and stretching exercises should be made an integral part of the thera­ peutic regimen.

The use of a pylon that can be adjusted in all planes and the use of an artifical foot have been advocated by Burgess.4 He noted that the foot attachment not only provided a wider base of support, but also decreased the vertical dis­ placement of the hip joint during stance phase. If an artificial foot is available, it should be used. However, no serious deterrents to reha­ bilitation were found with the use of a "pegleg," and errors in gait were easily corrected upon

procurement of the final prosthesis. Blashy and Morelewicz have reported the successful use of a pylon with a free knee for flexion and ex­ tension, and a lower leg terminating in a rub­ ber-tip base.17

For older patients with AK amputations the quadrilateral socket with Otto Bock knee has been employed as the prosthesis of choice at this hospital. This knee mechanism has the ad­ vantage of locking during as much as fifteen degrees (0.26 rad) of flexion at the knee joint, thus helping to decrease the patient's instability during the stance phase.

The patient must be taught proper hygienic techniques in the care of his stump and stump wearing apparel. This procedure should be initiated after the stump has been reduced in size and prosthetic training has been instituted with the final prosthesis. As Vitali has men­ tioned, continuing deep breathing and postop­ erative coughing exercises for patients with pul­ monary disease are important.16

CONCLUSION

To facilitate maximal patient care without demanding excessive time from the attending surgeon, the therapist should be trained in the application of the total contact plaster cast. These plaster cast sockets should be changed and stump conditions checked at least once a week for the first three to four postoperative weeks. This procedure would help minimize the possibility of undetected infection. When a prosthetist is not immediately available, this procedure could be utilized by rehabilitation clinics. A surgeon and physical therapy staff with experience in this procedure can use basic pylon accessories for the successful performance of this technique.

REFERENCES

1. Dederich R: Technique of myoplastic amputations. Ann Roy Coll Surg Eng 40:222-226, 1967

2. Bechtol CO: The fittings of a lower-extremity pros­ thesis in the immediate postamputation period. Arch Phys Med 48:145-146, 1967

3. Russek AS: Pre- and postoperative management of po­ tential diabetic amputee. New York J Med 66:1659- 1662, 1966

4. Burgess E: Immediate postsurgical prosthetics in the management of lower extremity amputees. Veterans Administration, Washington, D.C., 1967

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5. Kohn KH, Perlman L, Marcel N, et al: A multi­ phasic study of lower extremity amputees. JAMA 199:537-542, 1967

6. Lim RC Jr, Blaisdell FW, Hall AD, et al: Below-knee amputation for ischemic gangrene. Surg Gynec Obstet 125:493-501, 1967

7. Baddeley RM: A trial of conservative amputations for lesions of the feet in diabetes mellitus. Amer Surg 30:431-433, 1964

8. Felder DA: Pain and amputations for circulatory dis­ ease. Phys Ther Rev 40:183-186, 1960

9. Cummings V, Anderson AD, Levine SA, et al: The elderly medically ill amputee. Arch Phys Med 44: 549-554, 1963

10. Bugel HJ, Carlson RI: A study of lower extremity amputees. Amer J Phys Med 40:93-95, 1961

11. Record EE: Surgical amputation in the geriatric pa­ tient. J Bone Joint Surg 45A: 1742-1749, 1963

12. Bradham RR, Smoak RD: Amputations of the lower extremity used for arteriosclerosis obliterans. Arch Surg 90:10-64, 1965

13. Eraklis A, Brownell W: Below-knee amputations in patients with severe arterial insufficiency. New Eng J Med 269:938-943, 1963

14. Grynbaum BB, Gordon EE: Rehabilitation of the elderly amputee. J Chronic Dis 4:292-295, 1956

15. Claugus CE, Graham GC, Bowling EC, et al: Amputa­ tion of the lower extremity for arteriosclerosis. Arch Surg 76:992-996, 1958

16. Vitali M: Modern concept of the general manage­ ment of amputee rehabilitation including immediate postoperative fittings. Ann Roy Coll Surg Eng 40: 251-260, 1967

17. Blashy MR, Morelewicz HV: Lower extremity pros­ theses for patients past fifty. Arch Phys Med 39:497- 502, 1958

the authors

Steven L. Wolf, an instructor at the Sargent College of Allied Health Professions, Boston University at the time this article was written, is now working toward his doctoral degree in anatomy at Emory University. He holds an A.B. degree in biology from Clark University, and a master's degree in physical therapy from Boston University. He is a member of the Massachusetts chapter of the American Physical Therapy Association, the American Association of University Profes­ sors, and the Association of Schools of Allied Health Professions.

Joseph K. Reed, Jr., was chief of physical therapy at the U.S. Public Health Service Hospital in Boston, Massachusetts at the time the article was written. He holds a bachelor's degree in health and physical edu­ cation from West Chester State College and a certificate in physical therapy from the University of Kansas. Recently he completed the certificate curriculum of the Prosthetics-Orthotics Program at the University of California at Los Angeles. He is presently working with the prosthetic-orthotic program at the U.S. Public Health Service Hos­ pital in Carville, Louisiana.

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