Amputation,Stump care, phantom limb pain and gait training in lower limb

1. STUMP CARE, PHANTOM LIMB PAIN , GAIT TRAINING IN LOWER LIMB HARSHITA YADAV M.P.T ( ORTHOPAEDICS)

2. 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.

3. 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, 7 th ed.)

4. 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)

5. 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

6. 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

7. CAUSES CONGENITAL ACQUIRED - Vascular - Trauma - Infection - Neoplasm - Iatrogenic - - Neuropthic ( Rehabilitation S Sunder 3 rd ed.)

8. CONGENIAL ANOMALY

9. PERIPHERAL VASCULAR DISEASE

10. TRAUMA (severe tissue damage) – traumatic amputation

11. MALIGNANT TUMOUR

12. SCLERODERMA

13. DIABETES CRUSH INJURY

14. BURNS FROTBITE

15. 90 % amputation – peripheral vascular disease Young patient – trauma/ malignancy Absolute indication – irreversible ischaemia : disease or trauma ( Campbell’ s operative orthopaedics , vol 1, 7 th 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 )

16. PRINCIPLES GENERAL SURGICAL PRINCIPLES PRINCIPAL (Rehabilitation S Sunder 3 rd ed.)

17. 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 3 rd ed.)

18. 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 3 rd ed.)

19. 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

20. 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, 7 th ed.)

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

22. MYODESIS - Muscles & fasciae are sutured directly to the distal residual bone through drill holes. Muscles inserted function better , resulting in good prosthetic control. Procedure compromises blood supply to the muscles & hence is contraindicated in patients with severe peripheral vascular disease. Sometimes myodesis fails even with best care. (Rehabilitation S Sunder 3 rd ed.) SURGICAL PROCEDURE

23. 2. MYOPLASTY – 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. Muscles must be stretched enough so that they control the residual limb. Muscles sutured to each other provide distal soft-tissue padding over the residual bone. Sometimes a painful bursa develops between the soft tissues & underlying bone and some of these bursa can become infected & painful. 3. OSTEOMYODESIS – Similar to myodesis but the periosteum is stripped. This enables bone growth in that area. (Rehabilitation S Sunder 3 rd ed.)

24. TYPES OF AMPUTATION (classified according to the surgical technique or the emergency of situation) 1.PROVISIONAL Used 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. DEFINITIVE Used 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 3 rd ed.)

25. 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 3 rd ed.)

26. LEVEL OF AMPUTATION IN LOWER LIMB

27. HEMICORPORETOMY Amputation both lower limbs & pelvis below L4- L5 level HEMIPELVECTOMY Resection of lower half of the pelvis (Physical rehabilitation;Susan B O’ Sullivan; 5 th )

28. HIP DISARTICULATION Amputation through hip joint ; pelvis intact SHORT TRANSFEMORAL (Above knee) Less than 35% femoral length (Physical rehabilitation; Susan B O’ Sullivan; 5 th )

29. TRANSFEMORAL(above knee) Between 35% & 60% femoral length LONG TRANSFEMORAL(above knee) More than 60% femoral length

30. KNEE DISARTICULATION Amputation through the knee joint; femur intact SHORT TIBIAL(below knee) Less than 20% tibial length

31. TRANSTIBIAL(below knee) Between 20 -50% of tibial length LONG TRANSTIBIAL (below knee) More than 50% tibial

32. SYME’S AMPUTATION Ankle disarticulation with attachment of heel pad to distal end of tibia. Many include removal of malleoli & distal tibia/ fibular flares TRANSMETATARSAL Amputation through mid section of all metatarsals

33. PARTIAL FOOT/ RAY RESECTION Resection of the 3 rd , 4 th , 5 th metatarsals and digits TOE DISARTICULATION Disarticulation at the metatarsal phalangeal joint .

34. PARTIAL TOE Excision of any part of one or more toes

35. C losed amputation   one in which flaps are made from the skin and subcutaneous tissue and sutured over the end of the bone. A mputation in contiguity   amputation at a joint. A mputation in continuity   amputation of a limb elsewhere than at a joint. D ouble-flap amputation   one in which two flaps are formed. E lliptic amputation   one in which the cut has an elliptical outline.

36. 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.

37. 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.

38. 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)

39. 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)

40. POST – OPERATIVE DRESSINGS DRESSINGS RIGID DRESSINGS SEMI-RIGID DRESSINGS SOFT DRESSINGS SHRINKERS ELASTIC WRAPS

41. REMOVAL RIGID DRESSINGS NON REMOVAL RIGID DRESSINGS

42. SEMI-RIGID DRESSINGS ELASTIC SOFT DRESSINGS SHRINKERS

43. COMPLICATIONS HAEMATOMA DEHISCENCE/WOUND BREAKDOWN PROBLEMS ASSOCIATED WITH THE SURROUNDING SKIN BONE EROSION/ OSTEOMYELITIS INFECTION TISSUE NECROSIS STUMP OEDEMA . PAIN (Wound healing complications associated with lower limb amputation 29-Sep-2006 15:28:16 BST)

44. 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 BLISTERING CONTACT 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)

45. 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)

46. Classified as: PREPROSTHETIC Delayed healing Skin adherence to bone of residual limb Problems in shaping of residual limb Contractures Chronic wound sinus POSTPROSTHETIC Painful residual limb Adherence of skin to bone Insensitive skin Poor Fit Boney overgrowth in children Degenerative arthritis Fractures (Atlas of Limb Prosthetics: Surgical, Prosthetic, and Rehabilitation Principles)

47. 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)

48. 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; 5 th ) PHANTOM LIMB PAIN

49. 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)

50. 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)

51. 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)

52. The pain may be localized or diffuse ; it may be continous or intermittent & triggered by some external stimuli. (Physical rehabilitation;Susan B O’ Sullivan; 5 th )

53. 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)

54. 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)

55. 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)

56. 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; 5 th ) MANAGEMENT FOR PHANTOM LIMB PAIN

57. 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)

58. PHYSIOTHERAPEUTIC MANAGEMENT PRE-OPERATIVE ASSESSMENT STRENGTH TRAINING POST-OPERATIVE PRE-PROSTHETIC ASSESSMENT STUMP STRENGTHENING STUMP TRAINING FOR PROSTHESIS POST-PROSTHETIC GAIT TRAINING STUMP HANDLING

59. PRE-OPERATIVE MANAGEMENT Training involves: Breathing exercises Strengthening exercises Mobilization exercises Bed mobility Transfers Stabilization exercises Wheelchair training Strengthening exercises Bed mobility and transfers Wheelchair training

60. 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

61. PRE-PROSTHETIC

62. 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

63. 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.

64. RESUDIAL LIMB WRAPPING Eary wrapping provides a no. of positive benefits : Decrease odema & venous stasis Assist in shaping Help in counteract contracture Provide skin protection Reduce redundant tissue problems Reduce phantom limb sensation and discomfort Desensitize the residual limb with local pain

65. Residual limb wrapping

66. Post-operative stump training Exercise Massage Pressure Mobilization Strengthening PPAM aid for pressure tolerance training

67. Short arc quadriceps

68. Straight Leg Raise

69. Ankle Pumps

70. Side Lying Hip Abduction - Modified

71. Side Lying Hip Abduction - Advanced

72. Prone Hip Extension

73. Prone Hip Extension (Sound Limb)

74. Prone Adductor Squeeze

75. Prone Knee Flexion

76. Push-ups

77. Quadruped Leg Lift

78. Abdominal Curl-up

79. Bosu Head Twists

80. Bosu Ball Exercises

81. POST-PROSTHETIC

82. Prosthetics It is a replacement of substitution of a missing or a diseased part

83. Types of Prosthesis

84. Ideal prosthesis Fits comfortably Function well Looks presentable Fit as soon after the operation

85. Classification Endoprosthesis - implants used in Orthopaedic surgery eg ; austin moore Prosthesis Exoprosthesis -external replacement for a lost part of the limb

86. TYPES Temporary – Used following amputation till paient is fitted with permanent prosthesis eg;pylon Permanent prosthesis

87. 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

88. DONNING & DOFFING

89. Center of gravity