Amputation

Benjamin K. Potter, MD

Bradley M. Ritland, MD

Dr. Potter or an immediate family member serves as an unpaid consultant to Biomet; and serves as a board member, owner, officer, or committee member of Clinical Orthopaedics and Related Research, the Journal of Orthopaedic Trauma, the Journal of Surgical Orthopaedic Advances, and the Society of Military Orthopaedic Surgeons. Neither Dr. Ritland nor any immediate family member has received anything of value from or has stock or stock options held in a commercial company or institution related directly or indirectly to the subject of this article.

Introduction

Loss of a limb(s) represents a life-changing physical, functional, social, and psychological event for any patient. While the need for sound psychosocial support, care, and well-being following major extremity amputation cannot be overemphasized, physical therapy and rehabilitation concerns remain crucial to successful outcomes. In addition to restoring mobility and/or function, a thorough and complete rehabilitation process may improve the self-esteem, body image, personal and societal acceptance, and independence of persons with limb loss. Depending on premorbid function, medical comorbidities, indication for amputation(s), amputation level(s), and patient goals, desired outcomes range widely from wheelchair mobility with functional independence to near-complete recovery of function with aggressive pursuit of recreational or competitive athletics through adaptive or conventional means. Developing practical goals and a roughly targeted timeline shortly after amputation, in collaboration with the patient, the patient’s family, and the surgical and rehabilitation team can address early expectations while providing necessary hope and encouragement. Specific advanced training in rehabilitation of the upper or lower extremity amputee is useful in achieving optimal results.

Surgical Procedure

Given the myriad conventional and described major amputation levels and technical variations, a detailed description of each is beyond the scope of this chapter. Furthermore, distinct therapeutic and surgical amputation considerations vary greatly based on the indication for major extremity amputation, be it trauma, oncologic, infectious, congenital, or dysvascular and/or diabetic. The ideal residual limb preserves a mobile joint where possible, is cylindrical in shape with a durable and sensate skin, and is free of neuromas and deep skin invaginations. However, a few general principles are broadly applicable to upper and lower amputations that are extremely important.

First, all diseased tissue, whether traumatized and contaminated, dysvascular, infectious, or neoplastic, must be removed to avoid recurrence of the disease process, amputation failure, and early revision. All large and named vessels should be securely ligated. As all cut nerves form neuromas, named nerves should transected distally and buried proximally to avoid symptomatic neuromata without deinnervating functionally important proximal muscle groups or those useful for myoelectric control.

Next, the goal of amputation surgery is to provide a robust, healthy soft-tissue envelope that can biologically heal and provide a durable, ideally painless, terminal residual limb that can tolerate the functional demands of the patient—most commonly the pressure and shear of regular prosthesis utilization. As such, the soft-tissue envelope remains at least as important as the underlying osseous platform in achieving these goals. A stable myodesis and (secondary) myoplasty are important for achieving these goals, particularly for transfemoral amputations: both techniques improve terminal residual limb control, stabilize and anchor distal padding, and thus prevent soft-tissue retraction. Amputation level and bone cut selection should thus be based on the available soft tissue in addition to functional considerations. Skin grafts are variably tolerated depending on the location on the residual limb, the amputation level, and the underlying soft tissue. Grafts are generally manageable over healthy underlying muscle and padding, but are prone to breakdown and late revision if performed directly over bone or marginal soft tissue, particularly on the terminal aspect of the lower extremity amputation. Free-tissue transfers may be indicated to salvage a functional knee or elbow joint, and can sometimes be innervated to provide protective sensation. With the exception of well-conceived and padded
disarticulations, adequate space should be left for functional prosthetic components. Extra-long, or novel, amputation levels are to be avoided, as these often lack adequate soft-tissue padding and provide little space for prosthetic components; as such, these levels tend to offer the limitations of both the more proximal and distal amputation levels without conferring the full benefits of either.

Last, some form of rehabilitation is indicated following any major extremity amputation. The intensity of this rehabilitation may vary based on the indication for amputation, associated injuries or medical comorbidities, and functional potential and wishes of the patient with limb loss. For some diabetic or dysvascular patients with multiple amputations or severe cardiovascular disease, simply improved transfer capacity and independence may be the full extent of the rehabilitation potential and goals. The remainder of this chapter is directed largely at patients with at least some ambulatory potential (following major lower extremity amputation) or prosthetic use potential for assisting with activities of daily living (ADLs) following major upper extremity amputation. Fortunately, most patients with adequate blood supply to heal a major amputation(s) will also have adequate skin tolerance to be able to tolerate at least limited prosthesis wear at those levels.

Complications and anatomic difficulties are common following major amputation. In addition to physical and occupational therapist and prosthetist care, regular orthopaedic surgery and physiatrist follow-up is essential in order to minimize secondary morbidity due to complications. These visits can identify both overt surgical complications and persistently symptomatic residual limbs with correctable problems such as wound or residual limb breakdown, infection, myodesis failure, heterotopic ossification, and symptomatic neuromata. Diligent attention to, and correction of, these concerns can make the crucial difference between a content and functional amputee and a dissatisfied and truly disabled one.

Postoperative Rehabilitation

Similar to any surgical procedure, there are protocols that guide the rehabilitation process for patients sustaining major limb loss. Each patient is unique and will progress differently following the amputation; thus, each rehabilitation program should be individualized. The comprehensive rehabilitation program should commence as soon as practicable—in some cases, prior to performing the amputation or wound closure—and progress each patient aggressively, but as individually tolerated, through each phase.

Regardless of the indication for amputation, the limb(s) involved, or the number of joint levels lost, the primary goal of the rehabilitation team should be to return the patient to the highest level of achievable and desired function. The rehabilitation team members should be the primary advocates for the patient and should develop an individualized rehabilitation program to help the patient achieve his or her goals. Be open-minded with the patient’s goals and aspirations early on; over time, the patient will gain a better understanding of achievable function and limitations. Conversely, providers should not overpromise a patient and the patient’s family with regard to potential function. Encouraging the patient to have realistic goals and expectations early will set up the patient for success throughout the rehabilitation program. The rehabilitation team should utilize appropriate, evidence-based techniques to optimize the functional recovery of the patient and goals should be continuously updated throughout rehabilitation.

Initial Management/Preprosthetic Training

The goal of initial management is to thoroughly evaluate, educate, and adequately manage the patient perioperatively, generally in preparation for a prosthesis. A thorough evaluation of the entire patient, not just the limb(s) lost, is critical. Assessing the surgical location, sensation, pain/sensitivity, strength, flexibility, endurance, and functional capabilities of the patient will lay the foundation for the entire rehabilitation program. Once the evaluation is complete, specific focus areas include educating the patient and family members, reducing pain/edema, promoting residual limb healing, wheelchair management and/or ambulation with appropriate assistive devices, preventing loss of motion/strength/functional status, and optimizing core strength and cardiovascular fitness (Table 77.1).

Following the initial assessment and introductory therapy sessions with the patient, the provider progresses every aspect of the rehabilitation program. The focus is on optimally preparing the patient for the prosthesis and mitigating any factors that may limit progression (e.g., contractures, atrophy, deconditioning).

Rigid dressings (e.g., casting) can be useful for wound protection in patients at high risk for falling as well as for contracture prevention. This modality is generally utilized in patients who have difficulty complying with early rehabilitation or in whom delayed wound healing is anticipated. The rigid dressing may also be fitted with an immediate postoperative prosthesis. These casts, although useful, must be meticulously and adequately padded to prevent skin breakdown, particularly over osseous prominences (e.g., the patella).

Exercises should be continuously modified to challenge the patient to prepare the muscles important for gait and physical functioning, even when patients remain on bed rest or are wheelchair bound. The rehabilitation program should continue to incorporate flexibility, strengthening, balance, and cardiovascular exercises. Patient motivation and focus on performing the exercises with proper form and technique are critical. Functional training and multiplanar activities should be implemented as soon as appropriate based on the injury pattern.

Patient/Family Member Education

The patient must be educated on the injury/amputation, expectations in rehabilitation, general timelines of expected milestones, and the anticipated rehabilitation course of action. These are described by all members of the medical team, who must engage the patient and family members in the process of recovery. New amputees should also be encouraged to look at,
touch, and massage their residual limb(s). This can improve patient comfort with and acceptance of the amputation, as well as helping to desensitize the residual limb in the early postsurgical period.

Table 77.1 INITIAL MANAGEMENT/PREPROSTHETIC TRAINING

	Upper Extremity	Lower Extremity
Pain Management	Pharmaceutical interventions (NSAIDs, narcotic, gabapentinoids, tricyclics), patient controlled anesthesia, sciatic catheter, transcutaneous electrical nerve stimulation (TENS), heat, cold, desensitizing/tapping techniques, mirror therapy
Core Exercises	Lumbar stabilization program, plank exercises, prone extension exercises
Strengthening	Shoulder: flexion, extension, abduction, adduction Elbow: flexion, extension Intact limb strengthening, as tolerated	Hip: flexion, extension, abduction, adduction Knee: flexion, extension Intact limb strengthening, as tolerated
Stretching	Avoid contractures. Chest, scapular protractors/retractors, shoulder flexors, abductors, rotators	Avoid contractures. Hip flexor/abductor, hamstring, abdominal, lumbar
Cardiovascular	Upper body ergometer, ergo skier, rope-pull machine, rock wall treadmill, rowing, cycling, elliptical, treadmill
Balance	Perform seated and standing, as indicated. Alter surface, provide resistance/perturbations, and conduct additional tasks/movements as indicated.
Ambulation	Begin in parallel bars, then transition to assistive device (crutches or walker), as indicated
NSAIDs = nonsteroidal anti-inflammatory drugs, TENS = transcutaneous electrical nerve stimulation.

Early Functional Training

Encourage early independence with bed mobility, transfers, ADLs, and any mobility assistive device. Pay special attention to protecting the residual limb during this functional training. Falls resulting in contusions, fractures, frank wound dehiscence, or even simply loss of patient confidence and security substantially slow rehabilitation progress. Using appropriate adaptive devices or techniques will help build the patient’s confidence with these activities and prevent or mitigate setbacks.

Edema Control

Following an amputation, compression is arguably the most important method of edema control because of the effect it has on the shape and size of the residual limb and on the integrity of the incision. Compression techniques and dressing types can vary. A compressive wrap applied in a figure-of-eight pattern or a stump shrinker are commonly used. Whether using rigid or soft dressings, it is important to fit the patient with the desired compression device over the residual limb as soon as possible, ensuring distal-to-proximal compression. Compression should be aggressively progressed to mitigate postoperative swelling and to assist with residual limb shaping. Inappropriate application leads to proximal constriction and a bulbous limb, which is difficult to fit with a prosthesis. Icing techniques are also appropriate, but pay close attention to areas of decreased sensation to avoid thermal injury and skin compromise. Avoid keeping, or allowing the patient to maintain, the residual limb in dependent positions for extended periods.

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