Amputation and prosthesis

It Includes
Different types of Amputation
Prosthesis
Nursing Management

1. Amputation And Prosthesis Presented by: Anjali Arora M.Sc. Nursing -1 ST Year College Of Nursing Institute Of Liver and Biliary Sciences

2. Name Of Evaluator: Ms. Sarita Ahwal (Assistant Professor)

3. As a punishment in Islam – According to Islamic Sharia Law, the punishment for stealing is the amputation of the hand & after repeated offense, the foot (Quran 5:38) This controversial practice is still in practice in countries like Iran, Saudi Arabia & Northern Nigeria. Sometimes professional Athletes may choose to have digit amputation to relieve Chronic Pain & Impaired Performance Australian footballer Daniel Chick

4. AMPUTATION

5. Removal of body part, often an “ extremity ”

6. Amputatio – Latin noun from verb Amputare Amputare – to cut off or cut away, derived from 1. Amb: about and around. 2. Putare: to prune or to lop The verb “Amputare” was employed to cutting off the hands of criminals. “ Trans-osseous removal of a limb or part of it” Introduction

7. History Surgeons amputating a man’s leg, 1793 Ambroise Pare (French Surgeon)

8. BACKGROUND  Due to a lack of analgesics and narcotics the operation had to take only a few minutes known as "classic circular cut” (i.e., detachment of the skin, muscles, and bone at the same level). Petit recommended that we transect the skin first and the muscles and bone more proximally ("two-stage circular cut," 1718) Bromfield approved that the skin be cut first, the muscles more proximally and the bone most proximal ("three-stage circular cut," 1773). Langenbeck (1810) changed the operative technique in that they used a soft-tissue flap to cover the bone without tension ("flap amputation").

9. Robert Liston(1794-1847) Pioneering Scottish surgeon. Most famous cases Able to perform the removal of a limb in an amputation in 28 seconds, Liston's most famous case Second most famous case – Amputated the leg in 2.5 minutes , but in his enthusiasm the patient's testicles as well Famous for his skill in an era prior to Anaesthetics, when speed made a difference in terms of Pain and Survival

10. Early Surgical Amputations

11. Introduction Early Surgical Amputations Limb was severed from an unanaesthetised patient. Stump was dipped in Boiling oil (Hemostasis) Stump was poorly suited for Prostheses. High Mortality Rate.

12. Definition Amputation “Surgical removal of limb or part of the limb through a bone or multiple bones” Disarticulation “Surgical removal of whole limb or part of the limb through a joint ”

13. Incidence Age: common in 50-75 years of age traumatic- in young age Sex: Approx . 75% male 25% female Limb: Approx . 85% - lower limb 15% - upper limb

14. Aims of Amputation Preservation of life by Ablation of diseased tissue (tumor or infection). Improvement of general health by Relieving symptoms Restoration of function or improve the patient’s Quality of life . Reduction of Pain Return patient to maximum level of Independent functions. Considered first part of a Reconstruction to produce a physiological end organ

15. MESS ( M ANGLED E XTREMITY S EVERITY S CORE) If score is: ≤ 6 =Limb Salvageable If score is: >6=Amputate Removes subjectivity from decision making in trauma cases. No scoring system can replace experience & good clinical judgment .

16. Indications COMMON CAUSES <50 years Injury > 50 years Peripheral Vascular Disease Less common: Infection (Gangrene) Malignancy Nerve injury Congenital anomalies Miscellaneous ‘DDD’ Dead Deadly Damn Nuisance Trauma- RTA, Gun shot Extreme heat and cold-Burn

17. Dead Deadly Damn Nuisance The only absolute indication for amputation is “ Irreversible Ischaemia ”

18. COMMON CAUSES Natural causes Accidental causes Ritual, Punitive & Legal Causes Cold steel & Gunshot causes

19. Natural Causes Congenital Absence Vascular Disease Frostbite Ergot and other toxins Wound Infections Diabetes Mellitus Tumours

20. Accidental Causes Falls when running or from heights Crushing by trees Savaging by crocodiles and sharks Effects of earthquakes, tsunamis and Violent storms

21. Ritual, Punitive & Legal Causes Curing local pain In removing deformity Infection or gangrene In saving lives

22. Cold steel & Gunshot causes Iron & steel weapons evolved fingers & hands Destructive gunshot wounding, associated with mortal sepsis Boiling oil

23. Classification of Amputation

24. Classification

25. In Utero Amputation or Congenital Amputation Constriction of fetal limbs by fibrous bands of amnion leading to strangulation of limb – Due to amniotic band syndrome i.e. rupture of inner amnion without rupture of outer chorion Acquired Amputation Therapeutic Traumatic Self-amputation Auto-amputation Criminal (e.g. Hand amputation of theft in Saudi) Classification

26. Self-amputation When a person has become trapped in a deserted place, with no means of communication or hope of rescue Performed for criminal or political purposes Body integrity identity disorder Auto-amputation Spontaneous detachment from the body due to destruction of the blood vessels Ainhum (Dactylolysis spontanea) Thromboangiitis obliterans (Buerger Disease/presenile gangrene) Classification

27. Body integrity identity disorder is a psychological condition in which an individual feels compelled to remove one or more of their body parts, usually a limb. Ainhum (dactylolysis spontanea) Painful constriction of the base of the fifth toe frequently followed by bilateral spontaneous autoamputation a few years later. Classification

28. Lower Limb Amputations Upper Limb Amputations Classification

29. Amputation of digits Metacarpal amputation Wrist disarticulation Forearm amputation Above-elbow amputation Shoulder disarticulation Upper Limb Amputations Below-elbow amputation

30. Amputation of digits Partial foot amputation Ankle disarticulation ( Syme’s Amputation ) Knee disarticulation Above-knee amputation Hip disarticulation Lower Limb Amputations Below-knee amputation

31. Early Amputation Can be done in cases of prolonged healing, when the body is exhausted and there is the risk of mortality. Delayed Amputation Primary :- During the first 24 h , before the development of inflammative changes in the site. The wound can be closed by the primary sutures. Secondary:- After 24 h. there is no absolute need for limb amputation; despite, the applied treatment is not effective and the life-threatening (deep burns ) Classification

32. Open Amputation (Guillotine Operation) It is done as an emergency procedure. After amputations, the wound is left open & not closed. (Open amputation with inverted skin flap) Closed Amputation It is done as an elective procedure. After amputations, the soft tissues are closed primarily over the bony stump. E.g., above knee, below knee etc. Myodesis – muscle is suture to bone Myoplasty – muscle is sutured to opposite muscle group under appropriate tension . Classification Nursing Textbooks Staged Amputation/Unclosed Amputation Closed Amputations

33. BACKGROUND  Due to a lack of analgesics and narcotics the operation had to take only a few minutes known as "classic circular cut” (i.e., detachment of the skin, muscles, and bone at the same level). Petit recommended that we transect the skin first and the muscles and bone more proximally ("two-stage circular cut," 1718) Bromfield approved that the skin be cut first, the muscles more proximally and the bone most proximal ("three-stage circular cut," 1773). Langenbeck (1810) changed the operative technique in that they used a soft-tissue flap to cover the bone without tension ("flap amputation"). flap Amputation

34. Classification Provisional amputation When primary healing is unlikely Amputate as distal as etiology will allow. Re-amputation perform when stump is ok Definitive end-bearing amputation Weight is taken through the end of the stump Definitive non-end-bearing amputation Commonest variety All upper limb & most lower limb amputations

35. Others

36. Provisional Amputation END BEARING AMPUTATION

37. Foot Amputation

38. Special types of Amputation Dupuytren’s Amputation :- amputation of the arm at the shoulder joint. Gritti -Stokes Amputation :- amputation of the leg through the knee, using an oval anterior flap. Hey’s Amputation :- amputation of the foot between the tarsus and metatarsus. Larrey’s Amputation :- spontaneous amputation;- loss of a part without surgical intervention, as in diabetes mellitus

39. Activity

40. CONTRAINDICATION Poor health that impairs the patient's ability to tolerate anesthesia and surgery. BUT, the diseased limb is often at the center of the patient's illness, leading to a compromised medical status. – i.e. removal of the diseased limb is necessary to eliminate systemic toxins and save the patient's life. “Correct decisions” are based on the patient as a whole, not solely on the extent of the limb injury…..

41. Diagnostic Evaluation Lab studies Hematocrit Creatinine (Muscle injury and necrosis, myoglobin enters the systemic circulation and can lead to renal insufficiency and failure) Potassium and calcium levels (may lead to cardiac arrhythmias and seizures). White blood cell count, C-reactive protein , Platelets and ESR Expect the C-reactive protein to be the first laboratory value to respond to treatment

42. Diagnostic Evaluation Imaging studies X-ray AP & Lateral view CT and MRI scanning (surgical margins are appropriate) Technetium-99m (99mTc) pyrophosphate bone scanning to predict the need for amputation in persons with electrical burns and frostbite. Doppler ultrasonography (Measure arterial pressure) – Patients with PVD, falsely elevated due to non-compressibility of the calcified arteries.

43. Diagnostic Evaluation Ischemic index (II): - This index is the ratio of the Doppler ultrasonography pressure at the level being tested to the brachial systolic pressure. An II of 0.5 or greater at the surgical level is necessary to support wound healing. Ankle-brachial index: - The II at the ankle level is believed to be the best indicator for assessing adequate inflow to the ischemic limb. An index less than 0.45 indicates incisions distal to the ankle will not heal.

44. Management Of Traumatic Amputation

45. Management Pre operative period Post operative period Pre-Prosthetic stage Prosthetic stage

46. Pre-operative care

47. Pre Operative Care Assessment Physical Social Psychological Training Re-assurance

48. Pre Operative Assessment Physical Affected and unaffected limb Muscle strength before level of amputation. Joint mobility and Functional ability Respiratory function Balance( sitting & standing) Social Family & friends supports Living accommodation – Stairs, ramps, rails, width of door, wheelchair accessibility Proximity of shops Psychological Patients psychological approach to amputation. Motivation to walk. Other psychological problems

49. Pre-operative Evaluation History : (Aetiology and Comorbidities) Physical Examination : (CVS, Renal & Nervous system) Investigation Optimization: Anaemia, hypotension, infection, nutrition Consultations: Nephrologist, Cardiologist, Neurologist Counselling & consent Procedure, anaesthesia, complications, prosthesis & limitations. MESS ≥ 6 (Removes subjectivity from decision making in trauma cases )

50. Pre Operative Training Basic Aims To prevent post operative complication To reduce the cost of rehabilitation To reduce the period of rehabilitation

51. Training Program To prevention of thrombosis: Maintaining circulation through movement of the other good limb. To prevent the chest complication: Deep breathing, coughing & postural drainage To relieve pressure: Pressure mobility of all the joints To improve mobility: Exercise and Teach the technique for mobility & limb positioning in bed. To educate the patient: Transfers, monitoring wheelchair, single limb standing & balancing Educate to detect the possible complications like – soft tissue tightness, pressure point, expected degree of pain & phantom pain.

52. Reassurance Psychological reassurance play an important role in recovery Reassurance with all possible encouragement Practical demonstration by who has undergone similar surgery.

53. Intra-operative care

54. INTRA OPERATIVE CARE Anaesthesia -Regional, G.A Antibiotics - Broad-spectrum, IV

55. Intra-operative Measures Tourniquets : desirable except in ischemic limbs. Level of amputation : it is very important to fit the prosthesis. Skin flaps : good skin coverage is important. Skin should be mobile & sensitive. Muscle : is divided at least 5cm distal to the level of bone section & sutured. Nerves : cut proximally & allowed to retract. Blood vessels : double ligated & cut, release tourniquet & hemostasis completed. Bone : section above level of muscle section. Drains : removed after 48 – 72 hours.

56. Post operative Care Pre Prosthetic Stage Post Prosthetic Stage

57. Goals of Post-operative Care Prompt, uncomplicated wound healing Control of edema Control of Postoperative pain Prevention of joint contractures Rapid rehabilitation

58. Postoperative care Requires Multidisciplinary team Overcome the psychological stigma (Persons are often viewed as incomplete individuals) Perioperative antibiotics DVT prophylaxis Pulmonary hygiene Pain management – Brief use of IV narcotics followed by oral pain medicine Conical Dressing (Soft dressing with crepe bandage/Rigid dressing with POP) Stump elevation (foot of the bed) Avoid flexion contracture at knee & hip

59. Immediate Post-Operative Care (Nursing) Amputation Bed: To take off the weight of the bed clothes off site of the operation. Purposes: 1. To Keep the stump in good position and watch for hemorrhage. 2. To allow the nurse to make frequent observations. i.e. after amputation of the leg without disturbing the patient.  

60. Procedure: When the patient is brought back from the operation theatre, fan fold the two sets of linen one side of the bed and receive the patient on the bed. Bed cradle is used to take off the weight of the top linen with 2 sand bags Cover the patient and keep him warm and comfortable .

61. Immediate care of limb Compression dressing: Dressing fitting immediately Absolute bed rest with limb elevation

62. Pre-prosthetic Stage: Surgery performed to prepare remaining tissue to best support a prosthesis.

63. Pre Prosthetic stage Breathing exercises to prevent respiratory complications. Brisk ankle & foot ex for unaffected leg to prevent circulatory complications (1st day) Positioning on bed : Stump should be parallel to the unaffected leg without resting on pillow. Patient should lie as flat as possible & progress to prone lying when drains are out. Prolong sitting on soft mattress can predispose to development of hip flexion deformity. Stump should be rest on board when sitting in wheelchair. Prolong sitting with knee flex should be avoided . Conical Dressing/ Flowtron /Stump compression socks or bandaging :

64. Flowtron Stump compression socks

65. CONICAL BANDAGE ABOVE KNEE BELOW KNEE

66. CONICAL BANDAGE Diagonal oblique & spiral turn should be used rather than circular turns to prevent tourniquet effect.

67. Pre Prosthetic stage Strengthening muscles are: Grasp stretch lying (shoulder extension & adduction) Grasp lying (elbow flexion) Sitting push up Stump exercise(when the drains are out) In BKA progress to strengthening against resistance. In AKA prone lying leg lifting against resistance

68. Pre Prosthetic stage Walking Re-education Partial weight bearing in parallel bar using pneumatic post amputation mobility aid (PPAM) 5 – 10 day post operatively Patient should wear normal dress & a good walking shoe on unaffected side. Initially preferred training in stable surface & progress to unstable surface. PPAM - Partial weight bearing early walking aid that used under clinical supervision from 5 -7 day postoperatively while the suture are still in the wound.

69. Ideal stump Conical Heal adequately Adequate muscle padding Thin scar not interfering with prosthesis Adjacent joint movements Adequate blood supply

70. Care of 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

71. Complications Early Bleeding & haematoma Flap necrosis wound infection Gas gangrene Stump pain Phantom sensation Hyperesthesia of stump Stump Edema Late Phantom pain Phantom limb Joint deformity Contractures Neuromas Bone overgrowth Causalgia Psychiatric symptoms Depression Anxiety Crying spells Insomnia Loss of appetite Suicidal ideation

72. Prevention of complications Hematoma PREVENTION – Meticulous hemostasis before closure – Use of drain – Rigid dressing MANAGEMENT – Compressive dressing – Evacuation (if associated with delayed wound healing with or without infection)

73. Prevention of complications Infection PREVENTION - Aseptic techniques in perioperative period MANAGEMENT - Immediate debridement and irrigation - Open wound management - Antibiotics according to intraoperative cultures

74. Prevention of complications Wound Necrosis PREVENTION Reevaluate the preoperative selection of the amputation level Transcutaneous oxygen studies Serum albumin and lymphocyte count Immune and nutritional status Smoking cessation MANAGEMENT open wound management – Discontinuing prosthetic use until wound has healed – Hyperbaric oxygen therapy – Revision of amputation

75. Prevention of complications Contractures PREVENTION Avoiding over tightening of the muscles and appropriate postoperative positioning maintained. Prolonged sitting with the hip and knee flexed should be avoided TRANSFEMORAL : lie in the prone position multiple times Exercises to strengthen the muscles controlling the joint MANAGEMENT Increased ambulation at knee joint Prosthetic modification Wedging casts or surgical release( severe fixed contracture)

76. Prevention of complications Phantom limb Pain MANAGEMENT Diverse measures : massage, ice, heat, increased prosthetic use Relaxation training. – No one specific method is universally beneficial

77. Prevention of complications Edema PREVENTION – Minimized by performing proper closure and Myoplasty. MANAGEMENT – Frequent alterations as needed to accommodate volume changes

78. PROSTHESIS

79. Prosthesis - In addition It is a replacement or substitution of a missing or a diseased part.

80. Prosthesis: It’s a device designed to replace A missing part of the body or to make A part of the body work better. Orthoses: It’s A device that supports or corrects the function of A limb or the torso.

81. Purpose Used to provide an opportunity to perform functional tasks , particularly ambulation which may not be possible without limb.

82. Basic features of a Prosthesis Sockets Suspension Joints Base

83. Factors To Be Consider Before Prescribing Prosthesis Age General physique of the patient Mental conditions Length of the stump Status of stump circulation Level of amputation Strength, ROM & mobility related body segment Requirement of job & daily living

84. Classification Endoprosthesis - I mplants used in ORTHOPAEDIC SURGERY Exoprosthesis- E xternal replacement for a lost part of the limb

85. Types of prosthesis TEMPORARY Used following amputation till patient is fitted with permanent prosthesis. PERMANENT PROSTHESIS

86. LOWER LIMB PROSTHESIS PROSTHESIS FOR BELOW KNEE AMPUTATION PROSTHESIS FOR HIP DISARTICULATION

87. FOOT PROSTHESIS ANKLE DISARTICULATION (SYME’S PROSTHESIS)

88. UPPER LIMB PROSTHESIS WRIST PROSTHESIS BELOW ELBOW PROSTHESIS DIGITS PROSTHESIS

89. SHOULDER DISARTICULATION PROSTHESIS ABOVE ELBOW PROSTHESIS

90. Jaipur Foot (India's Pride)

91. Functions: Comfort: Meet users need Fits Well Simple Easy to put on and take off Easily learned light weight Dependable Adjustable Cosmetics: Fabrication: Looks, smells ,sounds normal Readily and widely available Easily cleaned Strain resistant Specifications for ideal Prosthesis

92. Care with Prosthesis The process of training & re-education . It includes: Correct methods of applying & removing of prosthesis Early detection of any complication due to prosthesis Functions of various component of prosthesis Limitation of activities with prosthetic limb The patient must be encourage to be as Independent as possible GAIT TRAINING

93. Criteria for Gait Training Gait training should be perform in front of full length mirror to observe & correct any fault Increase the walking time each day Inspect the stump at the end of day Young, fit amputees will required 1week training Elderly, will required 2week or more training.

94. Choke syndrome:- Skin problems Painful residual limb Poor socket fit Foot alignment abnormalities Generalized fatigue Issues related to Prosthesis

95. Nursing Management

96. As sessment History Physical examination Assess any pre-existing illness

97. Nursing Diagnosis Acute Pain related to amputation. Impaired physical mobility related to loss of limb Disturbed body image related to amputation Impaired skin integrity related to surgical amputation Self care deficit: feeding, bathing, dressing, toileting related to amputation.

98. Nursing Diagnosis Risk of infection related to inadequate primary defenses (broken skin, traumatized tissue) Risk of ineffective tissue perfusion related to reduced arterial/venous blood flow, tissue edema , hematoma formation Low self esteem related to loss of body part.

99. Intervention Health Promotion Acute Care Pre-operative care Post operative care Ambulatory care Special considerations

100. Intervention Health Promotion Control of causative illnesses Teach patients to carefully examine their lower extremities daily,If the patient cannot do this, the caregiver should help. Instruct people in safety precautions for potentially hazardous work. This responsibility is typicially critical for the Occupational Health Nurse.

101. Intervention Acute Care Psychological and social implications Use therapeutic Communication to develop a realistic attitude about the future.

102. Intervention Pre-operative care Reinforce information Discuss general post operative care Tell the patient that the amputated limb may feel like it is still present after surgery. This phenomenon is called Phantom limb sensation .

103. Intervention Post operative care Carefully monitor the patient's vital sign. Assess dressings for hemorrhage and Use aseptic technique during dressing. Mobility with a wheelchair may be the most realistic goal as ambulation progress, phone limb sensation and pain will subside Mirror therapy Proper bandaging Rehabilitation program

104. Elevate the stump on a pillow for the first 24 hours following surgery to control edema. To prevent contractures, turn the patient prone for 15 to 30 minutes twice a day with the limb extended if the patient can tolerate it. If not, keep the joints extended rather than flexed. Patients may return from surgery with a soft dressing with pressure wrap, semirigid dressings including plaster splints, or rigid dressings, which are used with care because they reduce access to the surgical wound. They may return with an immediate postsurgical fitted prosthesis already in place. Explain that the device is intended to aid ambulation and prevent the complications of immobility.

105. Intervention Ambulatory care The residual limb is covered with a stocking to ensure good fit and prevent skin breakdown Instruct the patient to clean the prosthesis pocket daily with mild soap and rinse thoroughly to remove irritants Except Leather and metal parts. Also consider the condition of the patient's shoe (alters the Gait and may damage the prosthesis)

106. Intervention Special considerations Emotional implications as little time to adjust psychologically or to participate in Decision making process.

107. Amputation is a major health burden on the families, society, and on medical services as well. Traumatic limb amputation is a catastrophic injury and an irreversible act which is sudden and emotionally devastating for the victims. In addition, it causes inability to support self and the family and driving many patients toward various psychiatric disorders . Extensive information regarding the effects of amputation has not been ascertained and therefore it was decided to do a systematic review. The goal of this review was to provide comprehensive information of peer-reviewed papers examining the psychological distress among amputees in India . A search of the literature resulted in a total of 12 articles with varied sample size from 16 to 190. The sample has been largely comprised males with lower limb amputation caused by primarily traumatic ones, i.e., motor vehicle accident, railway track accidents, machinery injury, blasts, etc., The prevalence of psychiatric disorders among amputees has been found to be in the range of 32% to 84% including depression rates 10.4%–63%, posttraumatic stress disorder 3.3%–56.3%, and phantom limb phenomenon 14%–92%. Although the studies reported that symptoms of anxiety and depression become better over the course of time, however surgical treatment providers need to liaise with psychiatrists and psychologists to support and deal with the psychological disturbances.

108. Evaluation Accept changed body image and Integrate changes into lifestyle Have no evidence of skin breakdown Have reduction or absence of pain Become mobile within limitations imposed by amputation

109. Discharge Guidelines Inspect the residual limb daily. Discontinue use of the prosthesis if irritation develops. Wash the residual limb thoroughly each night and Rinse thoroughly and dry gently Wear only a residual limb sock in good condition and supplied by the prosthetics. Change residual limb sock daily. Use prescribed pain management techniques. Perform ROM to all joints daily .

110. Summary

111. Conclusion Amputation should not be seen as a failure of Rx , but rather as the first step towards a patient’s return to a more comfortable & productive life. It does not end in the operating room; post op care is equally important performed with skill used in any other reconstructive surgery.

112. References Selvadurai Nayagam , David Warwick. Orthopaedic operations; Apley’s system of orhtopaedics & fractures, 9th Ed; 12:325-328. Canale & Beaty : General principles of amputations: Campbell's Operative Orthopaedics, 11th edition. John Ebenezer: Amputations; Textbook of Orthopaedics, 4th Edition; 60:787-791. Tintle SM et. Al: Traumatic & trauma-related amputations: Bone Joint Surg Am. 2010 Dec 15;92(18):2934-45 .

113. Thank you