Post-operative evaluation

The history and physical examination remain the most important components of post-operative evaluation. A thorough review of patients’ previous activities leading up to the amputation is necessary, but there are key issues that have an impact on the immediate care and future care of patients with lower limb amputation. These key issues include the date when the problem first started, which may have limited patient mobility; the date of hospitalization, which may have severely limited patient activity; all surgeries leading up to and including the amputation, in addition to revisions or complications, which may have occurred post-operatively; names of surgeons involved for contact information to obtain further details as necessary or for future issues if complications should occur; and review of pain issues related to the knee amputation itself in addition to pain prior to and after amputation surgery. Three types of pain are defined: surgical pain related to the operation, phantom sensation with a simple awareness of the absent body part, and, phantom pain, in which there are painful or disturbing feelings arising from a missing body part. Treatments and management of these types of pain are reviewed in detail later. Patients must be reassured that adequate pain control will be provided as part of the post-operative rehabilitation program.

It also is important to review and assess patients’ post-operative therapy program and level of mobilization just before and after amputation surgery. It is not unusual for patients to have declined functionally as a result of preceeding complications that led to the amputation. Patients who have been non-ambulatory for more than 6 months have a much higher likelihood of complications, such as hip flexion contracture, deconditioning, and depression. Review of recent medications, laboratory tests, and studies that have been done is prudent to have a full awareness of patients’ underlying medical conditions before and after amputation surgery.

Current level of function for mobility and self-care serves as a starting point for a therapy program and helps in establishing short-term and long-term goals for patients. Patients with dysvascular disease and diabetes generally have had some time to think and prepare for the limb loss. The psychological adjustments, however, may still be difficult, because of concerns about return to their previous life and family obligations. It is important to inquire about patients’ concerns related to limb loss and future function and performance. An appropriate referral to psychological services is necessary to help manage this issue.

A thorough review of patients’ prior level of function and activities is helpful in establishing patients’ future goals. Carefully review the activities in the home, out of the home, and in the community. Simple questions—such as, When was the last time a patient walked on two feet unassisted?—are helpful in establishing patients’ previous level of mobility function. Inquire what distance they could tolerate walking before they became tired, short of breath, or developed chest pain. If they used assistive devices, clarify the type of device and how long it has been used. It is not unusual for patients to forget or slightly exaggerate their performance before amputation; therefore, collaboration with family members is helpful to ensure that the information is correct.

A standard review of systems should be incorporated into the history, including issues such as cardiac disease, chest pain, shortness of breath, and history of myocardial infarction or cardiac surgery. Review of systems should include issues related to falls before and after amputation, which may have been caused by balance disorder, dizziness, vertigo, or vision loss, and issues related to weight gain or loss, nutritional aspects, depression, and overall quality of life. Details of past medical history can be obtained from charts or from patients and, again, should include issues related to cardiopulmonary disease, renal disease, diabetes, and other major medical disease. Questions related to cognitive function, which may relate to early levels of dementia or impairment, are important to include. A social history helps establish what the home situation was and what the social support network was in the past and will be in the future. Details of home setup, such as stairs to enter and exit the house and any stairs or level changes within the house; access to the bedroom, bathroom, and kitchen areas; and doorways with configurations, should be included.

Examination of patients should be thorough and comprehensive (key areas are discussed later). In the review of cranial nerves, vision, oral movements, and swallowing issues should be covered carefully. Cognitive assessment and orientation should be assessed thoroughly for early signs of memory changes or dementia. Cardiopulmonary examination should include careful review of heart, lungs, and peripheral pulses, including carotid, femoral, popliteal, dorsalis pedis, and posterior tibialis pulses. Examination of the upper limb should include manual muscle testing of grip, intrinsic hand muscles, biceps, triceps, deltoid and shoulder depressors (pectoralis and latissimus). These muscles are critical for proper use of an assistive device for ambulation with and without a prosthetic. Sensation and fine motor skills in both hands should be assessed carefully as these are helpful in allowing patients to achieve independence in donning and doffing a prosthetic device. Cerebellar function should be assessed for balance issues.

Examination of the lumbar spine, including range of motion for flexion, extension, lateral bending, and rotation, is important because many lower limb amputees suffer lumbar or sacroiliac pain as a result of the biomechanical changes that occur during gait with or without prosthesis. Examination of the lower limb should include manual muscle testing of hip flexion, extension, abduction and adduction, knee flexion and extension, ankle dorsiflexion and plantarflexion, and inversion and eversion.

Overall assessment of skin integrity includes any open wounds, loss of hair, quality of the toenails, peripheral pulses (discussed above), and sensation in the lower limbs, including light touch, pinprick, and proprioceptive feedback. The remaining foot should be inspected carefully for the areas of pressure, callus, or severe dysvascular disease, as indicated by discoloration and cool temperature. Range of motion, including hip extension, knee extension, ankle dorsiflexion, and plantarflexion in the remaining foot, is important to allow patients to resume proper ambulation. Hip flexion and knee flexion contracture are common in hospitalized patients, particularly in patients with lower limb amputation. These may occur unilaterally on the side of amputation or bilaterally as a result of lack of mobility and ambulation for several weeks or months.

Examination of a residual limb should include careful assessment and documentation of the level of amputation with proper nomenclature and establishment of the bony length of the remaining segment. Quality and quantity of soft tissue coverage over the end of an amputation should be documented. Manual palpation of a residual limb to indicate areas of tenderness or increased sensitivity helps plan for tissue tolerance within the prosthetic device. Assessment of the surgical site for evidence of appropriate healing should be documented carefully. Sensation of a residual limb is helpful to identify areas of potential increased risk once use of a prosthesis is instituted. Description of the overall shape of the residual limb, such as bulbous, cylindric, or cone shaped, should be documented to help monitor shaping of the residual limb. Circumferential measurements of a residual limb—proximal, mid, and distal—should be taken to objectively document volume changes and limb shrinking. Any open wounds that are on a residual limb or remaining foot should be measured carefully for length, width, depth, and any undermining. It is helpful to document the quality of the wound in addition to the description of the depth of the tissues and the quality of the tissues remaining. Wound care management is discussed later.

Assessment of the functional capability of patients at the time of examination is helpful, including independence in bed mobility, transfers, sit-to-stand position on remaining limb, and standing balance on the remaining limb. Many patients are unable to stand immediately post-operatively. Most patients should be able to do this within several days after amputation, however. Overall standing balance and endurance should be assessed as part of the examination. If patients have initiated therapy and some mobility, then ambulating with a walker or crutches, including hopping on the remaining leg, should be assessed for strength, endurance, and safety.

Patient education

After the history and examination of patients are completed, it is the role of physicians and prosthetic and orthotic teams to educate patients and families regarding the entire program associated with prosthetic fitting and training, including a review of medical findings that are relevant to a prosthetic fitting and training program. An estimate of the time frame of prosthetic fitting and training is helpful to families and patients, because they have no sense of how long this process may take. Explanation and demonstration of prosthetic devices, components, and socket design are helpful once patients are ready to receive this information. Many patients have a preconception or false notion about the cosmesis or function of prosthesis, and these should be explored in detail. Establishment of functional goals and expectations, short term and long term, is done as early as possible. This helps patients make plans for discharge from the hospital and management at home. A thorough explanation of the physical demands and energy cost of prosthetic training is helpful for patients with underlying cardiopulmonary disease. Explanation of limitation of prosthetic use, such as impact on driving, climbing ladders, and ambulation outdoors on uneven terrain, should be reviewed as patients try to understand the overall rehabilitation process.

Patients should be educated on monitoring the skin on the residual limb and the remaining foot through the process of pre-prosthetic therapy, prosthetic fitting, and prosthetic training. Patients are their own best advocates to ensure proper healing of the residual limb and to prevent any injury or irritation to the remaining foot. The use of proper footwear, on the prosthesis and the remaining foot, is critical and is reviewed later.

Introduction of the other members of a prosthetic team should start early in the rehabilitation program. Each member has a separate role that should be clearly identified to patients and other team members. The physician directing the rehabilitation program is responsible for thorough evaluation of patients and for providing diagnosis, prognosis, and risk evaluation to patients and the remaining team members. If there are issues related to healing or to pain that have an impact on the therapy program or prosthetic fitting, these should be clearly conveyed to the appropriate individuals. Physicians also supervise other members and ensure proper follow-up and monitoring of the response to the treatment program. Physicians are responsible for generating prescriptions for the appropriate therapy program, prosthetic device, footwear for the remaining limb, and medications to manage pain or depression.

A certified prosthetist is a critical member of a prosthetic team and should be invited to participate in the evaluation process and recommendation for prosthetic design. A prosthetist is an expert on material, components, and design issues of prostheses and there should be open discussion with physicians and therapists on the most appropriate and optimal design for individual patients. A certified prosthetist is responsible for fabricating the prosthetic device, fitting of the device, and follow-up for modifications and adjustments of the prosthetic device. A prosthetist should communicate any issues or concerns with the team and provide feedback and follow-up regarding progress with prosthetic fitting and training.

A physical therapist becomes a team member immediately after surgery to initiate a pre-prosthetic therapy program and should be invited to participate in evaluation of patients and make recommendations for a pre-prosthetic and prosthetic therapy program. A physical therapist should be aware of underlying medical conditions and any risks and potential problems related to the amputation surgery as provided by the physician. Physical therapists should provide feedback to the physician and prosthetist related to a patient’s progress in muscle strengthening, range of motion, mobility, and self-care tasks. If there are issues or any discomfort during a physical therapy evaluation and treatments that may impair or impact a prosthetic fitting and training program, they should be conveyed immediately to the appropriate team member.

A certified pedorthist should be included to assist in recommendation and fabrication of appropriate footwear for the remaining limb. A pedorthist should be invited to participate in evaluation and management of patients on a regular basis. A pedorthist fabricates appropriate footwear, which often includes extradepth orthopedic-type shoes with a custom-molded foot orthotic to help protect the remaining foot. A pedorthist can participate in the education process related to monitoring and protecting the remaining foot. Regular follow-up with a pedorthist for replacement and adjustment of the footwear is necessary.

Psychological services often are needed for patients after any level of amputation. There is a cognitive and psychological change that occurs after limb loss similar to the grieving process when a friend or family member is lost. There are issues related to family structure, family unit, and interaction with friends that should be addressed by a licensed psychologist. This service should be offered to all patients and, at minimum, screening should take place. If patients seem to be adjusting well, then only periodic re-evaluation may be necessary by a psychologist.

Significant psychological issues that are present or appear later, however, may have a severe impact on the progress of patients in a rehabilitation program, and this information should be conveyed to the physician and other team members as appropriate.

Patients are key members of the prosthetic rehabilitation team. Patients are expected to cooperate with other team members in providing appropriate information throughout the history and examination. Patients are expected to remain compliant with the treatment and recommendations from each of the team members or to convey information if they are unable to be compliant with the treatment program. Patients should be willing to express concerns regarding pain, psychological issues and depression, or social issues that may impair their ability to participate and cooperate with the treatment program.

Patient education

After the history and examination of patients are completed, it is the role of physicians and prosthetic and orthotic teams to educate patients and families regarding the entire program associated with prosthetic fitting and training, including a review of medical findings that are relevant to a prosthetic fitting and training program. An estimate of the time frame of prosthetic fitting and training is helpful to families and patients, because they have no sense of how long this process may take. Explanation and demonstration of prosthetic devices, components, and socket design are helpful once patients are ready to receive this information. Many patients have a preconception or false notion about the cosmesis or function of prosthesis, and these should be explored in detail. Establishment of functional goals and expectations, short term and long term, is done as early as possible. This helps patients make plans for discharge from the hospital and management at home. A thorough explanation of the physical demands and energy cost of prosthetic training is helpful for patients with underlying cardiopulmonary disease. Explanation of limitation of prosthetic use, such as impact on driving, climbing ladders, and ambulation outdoors on uneven terrain, should be reviewed as patients try to understand the overall rehabilitation process.

Patients should be educated on monitoring the skin on the residual limb and the remaining foot through the process of pre-prosthetic therapy, prosthetic fitting, and prosthetic training. Patients are their own best advocates to ensure proper healing of the residual limb and to prevent any injury or irritation to the remaining foot. The use of proper footwear, on the prosthesis and the remaining foot, is critical and is reviewed later.

Introduction of the other members of a prosthetic team should start early in the rehabilitation program. Each member has a separate role that should be clearly identified to patients and other team members. The physician directing the rehabilitation program is responsible for thorough evaluation of patients and for providing diagnosis, prognosis, and risk evaluation to patients and the remaining team members. If there are issues related to healing or to pain that have an impact on the therapy program or prosthetic fitting, these should be clearly conveyed to the appropriate individuals. Physicians also supervise other members and ensure proper follow-up and monitoring of the response to the treatment program. Physicians are responsible for generating prescriptions for the appropriate therapy program, prosthetic device, footwear for the remaining limb, and medications to manage pain or depression.

A certified prosthetist is a critical member of a prosthetic team and should be invited to participate in the evaluation process and recommendation for prosthetic design. A prosthetist is an expert on material, components, and design issues of prostheses and there should be open discussion with physicians and therapists on the most appropriate and optimal design for individual patients. A certified prosthetist is responsible for fabricating the prosthetic device, fitting of the device, and follow-up for modifications and adjustments of the prosthetic device. A prosthetist should communicate any issues or concerns with the team and provide feedback and follow-up regarding progress with prosthetic fitting and training.

A physical therapist becomes a team member immediately after surgery to initiate a pre-prosthetic therapy program and should be invited to participate in evaluation of patients and make recommendations for a pre-prosthetic and prosthetic therapy program. A physical therapist should be aware of underlying medical conditions and any risks and potential problems related to the amputation surgery as provided by the physician. Physical therapists should provide feedback to the physician and prosthetist related to a patient’s progress in muscle strengthening, range of motion, mobility, and self-care tasks. If there are issues or any discomfort during a physical therapy evaluation and treatments that may impair or impact a prosthetic fitting and training program, they should be conveyed immediately to the appropriate team member.

A certified pedorthist should be included to assist in recommendation and fabrication of appropriate footwear for the remaining limb. A pedorthist should be invited to participate in evaluation and management of patients on a regular basis. A pedorthist fabricates appropriate footwear, which often includes extradepth orthopedic-type shoes with a custom-molded foot orthotic to help protect the remaining foot. A pedorthist can participate in the education process related to monitoring and protecting the remaining foot. Regular follow-up with a pedorthist for replacement and adjustment of the footwear is necessary.

Psychological services often are needed for patients after any level of amputation. There is a cognitive and psychological change that occurs after limb loss similar to the grieving process when a friend or family member is lost. There are issues related to family structure, family unit, and interaction with friends that should be addressed by a licensed psychologist. This service should be offered to all patients and, at minimum, screening should take place. If patients seem to be adjusting well, then only periodic re-evaluation may be necessary by a psychologist.

Significant psychological issues that are present or appear later, however, may have a severe impact on the progress of patients in a rehabilitation program, and this information should be conveyed to the physician and other team members as appropriate.

Patients are key members of the prosthetic rehabilitation team. Patients are expected to cooperate with other team members in providing appropriate information throughout the history and examination. Patients are expected to remain compliant with the treatment and recommendations from each of the team members or to convey information if they are unable to be compliant with the treatment program. Patients should be willing to express concerns regarding pain, psychological issues and depression, or social issues that may impair their ability to participate and cooperate with the treatment program.

Pre-prosthetic therapy program

A physical therapy program should be instituted almost immediately after amputation surgery. Most patients are able to participate in a therapy program, at least incorporating the upper limbs and remaining limb, shortly after surgery. Strengthening and range of motion of the amputation limb may be delayed a few days because of pain issues or concerns on the part of a surgeon; however, these should be treated or addressed as soon as possible. Strengthening of critical muscles to prepare for ambulation with or without a prosthesis is one of the primary goals of a pre-prosthetic program. In the upper limbs, the critical muscles include grip, intrinsic muscles of the hand, elbow extensors, and shoulder depressors. Patients can start a simple program of wheelchair press-ups to help strengthen all these muscles simultaneously. In the lower limb, the critical muscles include hip extensors and abductors, knee extensors, and ankle dorsiflexors and plantarflexors in the remaining limb. It is important to maintain or improve range of motion at the critical joints, specifically hip extension, knee extension, and ankle dorsiflexion and plantarflexion, during the pre-prosthetic time. It is common for patients to lose range of motion at the hip and knee quickly; therefore, full extension of the knee and at least 20° of extension of the hip should be goals during the pre-prosthetic time.

A physical therapist should be involved in shaping and shrinking of the residual limb. It is ideal to have the surgeon wrap a compressive dressing on the residual limb in the operating room immediately after surgery. This may stay on for 1 to 3 days based on surgeon recommendation. Once initial surgical dressing is removed, continued shrinking and shaping of a residual limb occurs with figure-of-eight Ace wrapping of the residual limb 23 hours per day. This Ace wrapping should be rewrapped several times per day to monitor the skin, provide hygiene to the skin, and assess the shape of the residual limb. Patients and families should be educated on proper Ace-wrapping technique. Patients and families, in addition to the medical team, can monitor skin integrity and healing.

Application of a rigid dressing at the time of surgery is an alternative method of management. The rigid plaster or fiberglass dressing prevents the usual post-operative edema from occurring and typically remains in place for 7 to 10 days. Removal of the rigid dressing after 7 days allows for inspection of the skin and surgical site. If there are no complications or concerns, a second rigid dressing can be applied for an additional 7 to 10 days or until the sutures/staples are removed. If patients have increasing pain or fever while the rigid dressing is in place, then the dressing is removed briefly for inspection and reapplied if there are no problems. If there are concerns about healing, then traditional management with Ace wrapping can be instituted at that time.

After staples and sutures are removed, shrinker socks can be used for continued shrinking and shaping. Desensitization of a residual limb through tapping, rubbing, or massage can be instituted shortly after amputation surgery. Patients who describe a phantom sensation or phantom pain should start this type of desensitization as early as possible to help control these feelings. Tapping, rubbing, and massage can initially be done over the Ace wrap and ultimately directly over the skin as the wound heals. Other pain control measures used in physical therapy include rubbing different textures on the skin and electrical stimulation with a transcutaneous electrical nerve stimulation (TENS) unit. A pre-prosthetic therapy program should include mobility activities, such as transfers to a wheelchair; transfers to critical areas, such as toilet areas; car transfers; and high/low transfers to the bed. Most patients should be able to achieve standing and hopping within 3 to 7 days after amputation surgery. Ideally, this can be started with the parallel bars in a therapy department and progress to a walker and crutches as patients improve. Careful cardiopulmonary monitoring is necessary in most patients with diabetes and dysvascular disease. Monitoring of blood sugar levels may be necessary as they often change in the time period immediately after surgery. Proper inspection of the remaining foot is necessary and should be instituted by a treating therapist; education of patients regarding inspection is helpful.