1. Rehabilitation of lower limb amputee By : Dr
Rehabilitation of lower limb amputee By : Dr.Hassan Hussien El- sharkawy

2. Objectives Definition of Amputation Statistics Reasons for Amputation
Types of Amputation
Psychological Support Preparation
Types of Surgery, Pre-op, and Post-op Care
Surgical Complications
Amputation Complications
Stump Care
Rehabilitation and Prosthesis
Case Study & Questions

3. What is an Amputation?
Amputation: the surgical removal of a part of the body, a limb or part of a limb
Amputation is the surgical removal of a part of the body, a limb or part of a limb to treat recurrent infection, gangrene in peripheral vascular disease; to remove malignant tumors; or to treat severe trauma. Amputation is used to relieve symptoms, improve function and save or improve the patients quality of life.

4. Statistics
Canadians with diabetes are 23 times more likely to be hospitalized for a limb amputation than someone without diabetes
More than 4,000 Canadians with diabetes had a limb amputated in 2006.
30% of Canadians with diabetes will die within one year of amputation. 69% of limb amputees with diabetes will not survive past five years
Lower limb amputations are 4 times more common than upper limb (infection) .
While over 90% of amputations caused by vascular disease involve the lower limb, nearly 70% of amputations caused by trauma involve the upper limb

5. Statistics
For both males and females, risk of traumatic amputations increased steadily with age, reaching its highest level among people age 85 or older
Limb amputations resulting from cancer most commonly involved the lower limb; above-knee and below-knee amputations alone accounted for more than a third (36 percent) of all cancer-related amputations.
There were no notable differences by sex or race in the age-specific risk of cancer-related amputations, though rates of limb loss due to cancer were generally higher among individuals other than African Americans.
In all age groups, the risk of dysfunctional vascular related amputation was highest among males and individuals who are African American

6. Causative Factors of Amputations
Peripheral arterial disease
Diabetes Mellitus
Gangrene (du to the complication of # & plaster cast ) .
Trauma (crushing, frost bite, burns)
Congenital deformities
Chronic Osteomyelitis
Malignant Tumor
Amputation are often made necessary by progressive peripheral arterial disease which is often a sequela of diabete mellitus, fulminating gas gangrene, trauma such as crushing injuries, frost bite, burns, electrical burns, congenital deformities, chronic osteomyelitis, or malignant tumor. Of all these causes peripheral arterial disease counts for the most amputations of lower extremities. The most frequent causes of upper limb amputation are trauma and cancer, followed by vascular complications of disease

7. Diabetes
Complications of diabetes that contribute to the increased risk of foot infection include:
Neuropathy
Sensory
Autonomic
Motor
Peripheral vascular disease .
Immuno-compromise
From 50-75% of lower extremity amputations are performed on people with diabetes. More than 50% of these amputations are thought to be preventable provided patients are taught foot care measures and practice them on a daily basis. Complications of diabetes that contribute to the increased risk of foot infection include: neuropathy, peripheral vascular disease, and immuno-compromise
There are 3 types of Neuropathy. Sensory Neuropathy leads to loss of pain and pressure sensation. Autonomic neuropathy leads to increased dryness and fissuring of the skin secondary to decreased sweating. Motor neuropathy results in muscular atrophy which may lead to changes in the shape of the foot.
PVD: Poor circulation of the lower extremities contributes to poor wound healing and the development of gangrene.
Immuno-compromise is caused when Hyperglycemia impairs the ability of specialized leukocytes to destroy bacteria. Thus in poorly controlled diabetes there is a lowered resistance to certain infections.

8. High Risk Characteristics for Developing Foot Infections
Duration of diabetes more than 10 years
Age > 40 years
History of smoking
Decreased peripheral pulses
Decreased sensation
History of previous foot ulcers or amputation

9. Proper Foot Care for Diabetics
Check your sound foot and residual limb for sores, cuts, blisters or other problems every day. Check your shoes for pebbles and foreign objects.
Wash your foot in warm, not hot, water. Dry it well, especially between the toes.
Trim toenails straight across.
Protect your foot from extreme hot or cold. If you are cold at night, wear socks.
Never use heating pads or hot water to warm your foot/feet.
Never go barefoot. Wear slippers or socks inside the house.
Always wear your prosthesis or use a mobility aid. Hopping on your sound foot can lead to injury from overuse or by stubbing your toes or falling.

10. Levels of Amputations Levels of amputations:
Amputation is performed at the most distal point that will heal successfully.
The site of amputation is determined by 2 factors:
Adequacy of circulation
Functional usefulness – ie. meet the requirements for use of a prosthesis.
The objective of surgery is to preserve as much extremity length as possible. Preservation of knee and elbow joints is desired. Almost any level of amputation can be fitted with a prosthesis. The amputation of toes and portions of the foot causes minor changes in gait and balance. A syme amputation is performed most frequently for extensive foot trauma and produces a painless, durable extremity end that can withstand full weight bearing. Below knee amputations are preferred to above knee amputations because of the importance of the knee joint and the energy requirements for walking. Knee disarticulations are most successful with young, active patients who are able to develop precise control of the prosthesis. When above knee amputations are performed all possible length is preserved. Muscles are stabilized and shaped, and hip contractures are prevented for maximum ambulatory potential. Most people who have a hip disarticulation amputation must rely on a wheelchair. Upper extremity amputations are performed to preserve the maximum functional length. The prosthesis is fitted early for maximum function.
POINT OUT SOME OF THE LEVELS

11. Pre-operative Assessment
Neurovascular and functional status of extremity
Function and Condition of residual limb (in case of traumatic amputation)
Circulatory status and function of unaffected limb
Signs & Symptoms of infection (culture required)
Nutritional Status
Concurrent medical problems
Current medications
Before surgery the nurse must evaluate neurovascular and functional status of the extremity through history and physical assessment. If the patient has experienced a traumatic amputation the nurse assesses the function and condition of the residual limb. The nurse also assesses the circulatory status and function of the unaffected extremity. If infection or gangrene develops the patient may have associated enlarged lymph nodes, fever, purulent drainage. A culture is taken to determine the appropriate antibiotic therapy. The nurse evaluates the patients nutritional status and creates a plan for nutritional care, if indicated. For wound healing a balanced diet with adequate proteins and vitamins is essential. Any concurrent health problems such as dehydration, anemia, cardiac insufficiency, chronic respiratory problems and diabetes mellitus need to be identified and treated so that the patient is the in best possible condition to with stand the trauma of surgery. The use of corticosteroids, anticoagulants, vasoconstrictors or vasodilators may influence management and wound healing.

12. Psychological Support Preparation
Emotional reaction to amputation
Circumstances surrounding amputation (ie. Traumatic versus surgical)
Occupational and social Rehabilitation
The nurse assesses the patient’s psychological status. Determination of the patients emotional reaction to amputation is essential for nursing care. Amputees often find it difficult to share their concerns about body image and relationships. However, this is a topic that must be addressed in a person's adjustment to life as an amputee. In the beginning, amputation, and the issues surrounding it, may feel overwhelming. Each person reacts to the news that they have or are about to become an amputee in their own way. Some people like to know well in advance as this gives them time to mentally prepare. Others prefer to have the amputation performed right away as all they will do until the surgery is performed is worry. More simply, they just want to get on with their lives as quickly as possible. It is important to remember that there is no right or wrong reaction to the news about your amputation. It can also be helpful to realize that amputations are performed to save or improve the quality of life of an individual.
It is interesting to reflect that amputation due to accident can leave a different mark on the psyche of the amputee, depending upon the circumstances under which the accident occurred. It can raise questions of guilt and blame, directed inwardly in some instances to the amputee himself or herself (i.e. Did I bring this on myself?). Blame is sometimes laid by the amputee on the doorstep of others if the circumstances of the accident would appear to support this.
Another set of problems of a psychological nature surround congenital amputees. Questions of cause and blame may run through all levels of the family. This negativity will be sensed by the child and, thereby, will affect the child's attitude too.
Setting aside all attempts at psychology, a simple fact becomes very clear indeed. There is absolutely nothing to be gained (and the risk of increased disability can result) if the amputee attempts to dwell upon the reasons for having become an amputee. Those involved in amputee care - and the amputee - must strive never to look back. The goal should be occupational and social rehabilitation.

13. Above the Knee Primary Amputation
Site of Amputation

14. Above the Knee
This is a pictorial Recap of surgery. The skin and bone is cut back to expose the bone. In some surgeries a saw is used while other may use a thin metal wire saw to cut through all the layers of the leg. The closure of the flap depends on the type of surgery.

15. Post- Operative Interventions
Monitor for complications
Pain management
Education & support
Promote mobility/ independent self-care
Enhancing Body Image
Promote wound healing
Monitor for complications such as hemorrhage, infection, and skin breakdown
Surgical pain can be affectively controlled with opioid analgesics and non-pharmaceutical interventions such as position changes, and places a light sandbag on the residual limb to counteract the muscle spasm. As always a good assessment of the PQRSTs of pain is important
As we have previously discussed….
Amputation of an extremity affects the patients ability to provide self care. The patient is encouraged to be an active participant in self care. The patient needs time to accomplish these tasks and must not be rushed. Practicing activity with consistent support of supervision in a relaxed environment enables the patient to learn self care skills. The patient and the nurse need to maintain positive attitudes and to minimize fatigue and frustration during the learning process. Independence in dressing, toileting and bathing depends on balance, transfer abilities and physiological tolerance of the activities. The nurse works with the PT and OT to teach and supervise the patient in these self care activities. The patient with and upper extremity amputation has self care deficits in feeding, bathing and dressing. Assistance is provided only as needed. The nurse encourages the patient to learn to do these tasks using feeding and dressing aids when needed. The nurse, therapists, and prosthetist work with the patient to achieve maximum independence.
Amputation is a reconstructive procedure that alters the patients body image. The nurse who has established a trusting relationship with the patient is better able to communicate acceptance of the patient who has experienced an amputation. The nurse encourages the patient to look at, feel and then care for the residual limb. It is important to identify the patients strengths and resources to facilitate rehabilitation. The nurse assists the patient to regain the previous level of independent functioning. The patient who is accepted as a whole person is more readily able to resume responsibility for self care, self concept improves and body image changes are accepted. Even with highly motivated patients this process may take months.
Promote wound healing by ensuring aseptic technique during dressing changes and handling the residual limb with care. The residual limb should not be placed on a pillow because a flexion contracture can occur. If the cast or elastic compression bandage inadvertently comes off the nurse must immediately wrap the residual limb with an elastic compression bandage. If this is not done excess edema will develop in a short time resulting in a delay in rehabilitation.

16. Skin Care & Stump Hygiene
Wash at night
Mild, fragrance free soap or antiseptic cleaner
Rinse well
Dry thoroughly
General wound care
The Stump
Cleansing the residual limb should be done at night. Morning washes are not advised unless a stump sock is worn because the damp skin can swell and stick to the inside of the socket.
Wet the skin thoroughly with warm water.
Use mild fragrance-free soap or an antiseptic cleaner.
Work up a foamy lather
Rinse with clean water, making sure all traces of soap are gone. A soapy film left on the skin may be an irritant.
Dry skin thoroughly.

17. Dressings

20. Hemorrhage Infection “
Surgical Complications
Hemorrhage
Infection “
Hemorrhage- due to severing of major blood vessels which can result in massive bleeding.
Infection – is a risk with all surgical procedures. The risk for infection increases with contaminated wounds after traumatic amputation

21. Complication of Amputations
Joint contractures
Energy issues
Phantom limb pain
Bony growth
Skin Breakdown
Blistering
Joint contractures- is caused by positioning and protective flexion withdrawal pattern associated with pain and muscle imbalance.
Energy issues- Leg amputees tire more quickly than their peers on an outing or may not be able to keep up the same pace. Their amputation is the reason for this. an amputee who walks the same distance as a non-amputee will have a higher level of oxygen consumption. For example, quoted figures for amputees with vascular deficiencies compared with non-amputees indicate an increase in oxygen consumption for:
below-knee amputees from 9% to 20%
above-knee amputees from 45% to 70%
bilateral above-knee amputees up to 300%
The next 3 complications will be discussed in greater detail in the next few slides.
Phantom limb pain – is caused severing of peripheral nerves
Bony growths- Bony overgrowth (sometimes called terminal overgrowth) can occur when an amputation transects the bone. It is characterized by swelling, warmth and tenderness at the end of the residual limb
Skin Breakdown – Skin irritation caused by the prosthesis may result in skin breakdown which will be discussed in the stump care portion of the presentation. The pictures are examples of different type of skin breakdowns that can occur
Necrosis

22. What is PLP? The somatosensory homonculus
Phantom Limb Pain
Phantom sensation is the conscious sensation that the amputated limb is still there – these sensations usually decrease over time. Phantom limb pain is a conscious feeling of a painful limb, after the limb has been amputated. Phantom limb pain can range in type and intensity. For example, a mild form might be experienced as a sharp, intermittent stabbing pain causing the limb to jerk in reaction to the pain - an example of a more severe type might be the feeling that the missing limb is being crushed. Usually phantom limb pain diminishes in frequency and intensity over time. For a small number of amputees, however, phantom limb pain can become chronic and debilitating because of the frequency and severity of the pain.
Until recently, the dominant theory for cause of phantom limbs was irritation in the severed nerve endings called "neuromas”. When a limb is amputated, many severed nerve endings are terminated at the residual limb. These nerve endings can become inflamed, and were thought to send anomalous signals to the brain. These signals, being functionally nonsense, were thought to be interpreted by the brain as pain. Treatments based on this theory were generally failures. In extreme cases, surgeons would perform a second amputation, shortening the stump, with the hope of removing the inflamed nerve endings and causing temporary relief from the phantom pain. But instead, the patients' phantom pains increased, and many were left with the sensation of both the original phantom limb, as well as a new phantom stump, with a pain all its own. In some cases, surgeons even cut the sensory nerves leading into the spinal cord or in extreme cases, even removed the part of the thalamus that receives sensory signals from the body.
However by the early 1990s it was demonstrated that that the primary somatosensory cortex undergoes substantial reorganization after the loss of sensory input. It was therefore theorized that phantom limb sensations could be due to this reorganization in the somatosensory cortex, which is located in the postcentral gyrus, and which receives input from the limbs and body. The input from extremities comes into the somatosensory cortex in an ordered way, the representation of which is referred to as the somatosensory homonculus (pictured here). Input from the hand is located next to the input from the arm, input from the foot is located next to input from the hand, and so on. One oddity is input from the face is located next to input from the hand. The areas in the somatosensory cortex that are near to the ones of the hand (the arm and face) will take over (or "remap") this cortical region that no longer has input.
This remapping was demonstrated through experiments where stroking different parts of the face led to perceptions of being touched on different parts of the missing limb.
What is PLP?
The somatosensory homonculus

23. Phantom Limb Pain: Coping Techniques
Acupuncture
Exercise
Anaesthetics
Heat
Biofeedback
Magnetic Therapy
Chiropractic
Massage
Cold
Medications
Cranial Sacral Therapy
Psychotherapy
Desensitization
Shrinker Socks
Dietary and Herbal Supplements
Wearing Your Artificial Limb
Electrical Stimulation
Techniques for Dealing With Phantom Limb Pain (another slide)
Acupuncture
Anaesthetics
Biofeedback
Chiropractic
Cold
Cranial Sacral Therapy
Desensitization
Dietary and Herbal Supplements
Electrical Stimulation
Exercise
Farabloc
Heat
Keeping a Journal
LaKOTA
Magnetic Therapy
Massage
Medications- Medications are useful in the treatment of pain (especially chronic pain). However, many amputees prefer to try other avenues of relief first. It is important for the amputee to understand all the possible side-effects of over-the-counter and prescription medications, including the implications of long-term use.
Anti-Inflammatory Drugs (examples: acetaminophen [Tylenol], aspirin, ibuprofen [Advil, Motrin]
Acetaminophen are all examples of medication which can reduce mild swelling or soreness, and are useful for mild to moderate pain. They are non-addictive and may be effective for occasional bouts of phantom pain. One amputee uses Tylenol Arthritis Pain for relief from his phantom limb pain.
Antidepressants (examples: Amitriptyline, Elavil, Pamelor, Paxil, Prozac, Zoloft)
Developed to treat depression, many antidepressants have been found to be useful in the treatment of many chronic pain conditions, including phantom limb pain. These drugs work centrally on the brain to either block or increase certain chemicals that help regulate normal brain function.
Anticonvulsants or anti-seizure medications (examples: Tegratol, Neurontin)
These drugs have also been found useful in the treatment of phantom limb pain. They act directly on the nerves both in the residual limb and in the brain to alter neurotransmission, thus calming nerves in the residual limb which may have become over-active following amputation. These drugs are prescribed in small doses and are gradually increased to a level which promotes relief. It is also very important to decrease the dose gradually before ceasing to take the medication.
Narcotics (examples: Codeine, Demerol, Morphine, Percodan, Percocet)
These drugs mimic the pain killing chemicals released by the brain in response to pain. Amputees who have only an occasional severe attack of phantom pain may benefit from a limited course of this type of drug. Narcotic prescription drugs are not suitable for all cases of phantom pain so it is important to speak with your doctor.
Meditation
Psychotherapy
Shrinker Socks
Wearing Your Artificial Limb - As well as improving circulation, putting on your artificial limb and moving around may also help alleviate phantom limb pain.

24. Levels of lower limb amputation

25. Prostheses
Devices to help shape and shrink the residual limb and help client readapt
Wrapping of elastic bandages
Individual fitting of the prosthesis; special care

26. Lower Limb Prosthesis Types of lower limbs prostheses :
Types of L.L. prostheses depend on different stages after amputation. There are three types:
- Immediate post- operative prosthesis.
- Temporary prosthesis
- Definitive prosthesis.

27. Types of Prosthesis

28. Prosthetics Leg Prosthesis (2 types):
An exoskeletal prosthesis has a hard outer shell made primarily of plastics and laminates.
An endoskeletal or modular prosthesis has the tube or pylon frame that acts as a type of “skeleton.”
A soft foam cover is usually applied over the prosthesis. The foam cover is shaped to match the remaining sound limb.
Arm:
A myoelectric arm, in which signals from muscles in the residual limb are sent via electrodes to the prosthetic hand to open or close it, is powered by a battery
The cheetah prosthetic which is pictured above has been riddled with controversy. Oscar Pistorius is a double below-knee amputee from South Africa who recently won the silver medal in the 400m at the South African senior athletics championships against an entirely able-bodied field. However, he may be excluded from further competing in "able-bodied" events because some feel that his artificial legs give him an unfair advantage by virtue of being longer then natural legs. Others say that his legs are a disadvantage, since unlike natural legs, they are merely akin to springs and can not generate energy like a natural leg.
It is important to consider culture and ethnic origin when discussing a prosthetic with patients. When I was in Haiti it was common for prosthetics to go unused as they were not made to match the skin tone of their wearer!

29. Rehabilitation There are 5 Stages of Rehabilitation:
Healing and Starting Physiotherapy
Visiting the Prosthetist
Choosing an Artificial Limb
Learning to Use your Artificial Limb
Life as a New Amputee
Stage 1: Healing and Starting Physiotherapy: Following the amputation, there will be a healing phase - during which time the incision and surrounding tissue will recover. This timeframe can vary between a matter of weeks, a couple of months or even more depending on the type of amputation, how much scar tissue may be involved and how the limb heals. In the hospital, the physiotherapist (PT) will teach exercises to improve muscle function and will show how to get around on crutches or a wheelchair (if it is required).
Stage 2: Visiting the Prosthetist: A prosthetist is the professional who makes the artificial limb (prosthesis). Once the clinic team is satisfied that the residual limb has healed well enough, a prosthesis can be fitted. A temporary prosthesis (more common for leg amputees) provides early mobility while allowing the residual limb to continue to shrink and change shape (which is normal following any amputation). Once the residual limb has settled into its final shape and the incision has healed, a "definitive" prosthesis (for permanent use) will be made.
Stage 3: Choosing an Artificial Limb(s): Factors to consider include level of activity, health, level of amputation, and importance of cosmetic look versus functionality.
Stage 4: Learning to Use Your Artificial Limb: The prosthetist or PT teach leg amputees how to walk with their artificial limb. This is called gait training. Arm amputees are trained by Ots and that may take longer and be more involved. OT also teach adaptive skills such as how to get dressed with one hand.
Stage 5: Life As a New Amputee: This stage is the return to their regular lifestyle and activities. Bigger stepping stones that many take longer to achieve include driving a car and returning to the work force.

30. Rehabilitation of lower limb amputee :
Therapy plays an integral role in preparing a patient for a lower-extremity orthotic or prosthetic device and training them with that device once it has been fabricated.
Once a patient receives a prosthetic or orthotic device, the therapist is then responsible for evaluating that patient with their device

31. Exercise After Amputation
ROM to prevent flexion contractures, particularly of the hip and knee
Trapeze and overhead frame
Firm mattress
Prone position every 3 to 4 hours
Elevation of lower-leg residual limb controversial
S&P

47. Case Study
John Rocke is a 45-year-old divorcee with no children. He has a history of type one diabetes mellitus and poor control of blood glu- cose levels. Mr. Rocke is unemployed and currently receives un- employment compensation. He lives alone in a second-floor apartment. Mr. Rocke had developed gangrene in the toe and failed to seek prompt medical attention; as a result, a left below- the-knee amputation was necessary.
What type of surgery did Mr. Rocke receive?
Open
Closed
Congential
Secondary
Open

48. Case Study
Mr. Rocke is in his second postoperative day and his vital signs are stable. The stump is splinted and has a soft dressing. The wound is approximating well without signs of infection. He has not performed ROM exercises or turning since his surgery, com- plaining of severe crushing pain in his left foot?
What type of pain is this?
Fibromyalgia
Somatic Pain
Phantom limb pain
Imaginary pain
PLP

49. Case Study
Which of the following post-operative complications would Mr. Rocke NOT experience?
Hemmorrhage
Joint Contractures
Skin Breakdown
Bony Overgrowth
D. Bony Overgrowth

50. Case Study
When the nurse goes into the room, he yells, "Get out! I don’t want anyone to see me like this.”
What would be a priority nursing diagnosis for this situation?
Disturbed body image, dysfunctional grieving, ineffective coping

51. Case Study True or False:
Mr. Rocke should receive a diet high in protein, vitamins and simple carbohydrates
False: simple carbs are not recommeneded for diabetics although high protein and vitamins enhance wound healing.

52. Case Study
You are planning an education session to provide Mr. Rocke with information about the importance of stump care.
Which of the following statements that Mr. Rocke repeats back to you best demonstrates his understanding of good stump care?
I will wash my stump in the morning with cool water and Axe body wash.
I will wash my stump at night with fragrance free soap and warm water.
I will wash my stump in the morning with fragrance free soap and warm water
I will never wash my stump. B

53. References
Day, R.A., Paul, I., Williams, B., Smeltzer, S., Bare, B.G. (2009) Brunner and Suddarth's Textbook of Canadian Medical-Surgical Nursing, 2nd ed. Lippincott Williams & Wilkins
Canadian Association of Wound Care. (2011). Statistics on Diabetic Foot Ulcers. Retrieved from cawc.net/index.php/public/facts-stats-and-tools/statistics/
Mosby. (2008). Mosby's Dictionary of Medicine, Nursing & Health Professions. 8th ed. A Mosby Title
National Limb Loss Information Center. (2008). Amputation Statistics by Cause Limb Loss in the United States. Retrieved from < coalition.org/fact_sheets/amp_stats_cause.html>
National Limb Loss Information Center. Statistics on Hand and Arm Loss. Retrieved from <
Net Wellness. (2011). Amputation Overview. Retrieved from < healthtopics/amputation/overview.cfm>
War Amps (2009) Retrieved from < =1033>