Peri-operative management is care provided before, during and after surgery. Pre-operative management prepares the patient as best as possible for the loss of a limb and possible complications. Intra-operative care is provided in the operating room. Post-operative care starts from the post-anesthesia unit until complete healing, resolution of surgical sequelae and achieving all prosthetic rehabilitation goals. In upper limb amputations—which are commonly due to trauma—pre-surgical care may be minimal, which will shift the majority of the physiatric assessment post-surgical. 82% of lower extremity amputations are due to vascular conditions. Physiatric assessment can begin pre-operatively, to optimize timing of potential rehabilitation and any other factors that may affect overall patient function.
In 2005, 1.6 million people were living with an amputation with a projected prevalence that may double by year 2050. This increase in dysvascular disease has unfortunately led to increasing number of amputations each year. This, in turn, has significantly increased the critical role of Physiatry in evaluation and planning of perioperative management.
In two thirds of all lower extremity amputations, diabetes is a major risk factor, and in dysvascular disease, 55% will lose a second leg within 2-3 years. In upper limb, trauma is the leading cause of acquired amputation
2. ESSENTIALS OF ASSESSMENT
Throughout your assessment, the history and specific etiology of the amputation will guide a focused evaluation. Regardless of the amputation etiology, a comprehensive history should always include presence of co-morbid conditions that may affect outcomes, including peripheral vascular disease, claudication, diabetes mellitus, coronary artery disease, prior myocardial infarction, valvular disease, congestive heart failure, severe pulmonary disease, cognitive impairment, chronic pain, obesity, tobacco use, alcohol and illicit drug use, and psychiatric diagnoses.
The social history is especially important in the amputee population, including prior level of function, education, work/employment status, home environment and current/potential barriers to returning home. It should also include available social support system and patient goals including home, professional and social roles.
Similar to the history, the exam should focus on systems related to the amputation etiology and those that may affect outcomes. In addition to cardiac and pulmonary exams, suggested focus areas include:
Vitals: HR, BP, RR, Sp02, BMI and pain scale
Cognitive: level of alertness, orientation and ability to follow commands. Mini mental state examination
HEENT: vision screen (or documentation of recent testing)
Psychological: note any mood or behavior such as anxiety, depression, PTSD, anger issues
Skin: skin integrity, presence of edema, skin color, temperature and signs of infection, bony prominences that may affect prosthetic fit
MSK: contracture assessment with range of motion in all upper and lower extremity joints
Neuromuscular: balance, manual muscle testing including both upper and lower extremity strength
Vascular: pulses of residual and contralateral limbs, capillary refill
Insurance: K-level functional assessment
Overall, the role of physical therapy in the peri-operative period is to assess and maximize the patient’s strength, endurance, range of motion, and mobility status in preparation for potential prosthetic rehabilitation and minimizing complications like joint contracture and falls. Occupational therapy can address the patient’s self-care skills and equipment needs. Cognitive abilities, vision and psychological coping skills can be addressed by appropriate services as needed.
Relevant laboratory studies are based on the patient status and the setting in which the patient is seen in the post-operative period. These may be necessary for: 1. Surgical complications (anemia, fever); 2. Co-morbidities (renal disease, cardiac disease, diabetes mellitus). Vascular amputees are likely to have multiple co-morbidities that need more frequent monitoring.
Peri-operative imaging may be necessary to monitor patient status or assess for potential complications like pneumonia, congestive heart failure exacerbation, DVTs and heterotrophic ossification.
Early predictions of outcomes
Prognosis for survival following major amputation in the dysvascular population remains unchanged for decades (the 50/50 rule). Approximately 50% of these patients will die within 5 years, and 50% of the survivors will suffer a second major amputation within 5 years. Survival for patients with traumatic amputation is near normal.
Based on exam and assessment, prognosis can be reasonably estimated for prosthetic use and ambulation. If the etiology is trauma or tumor, success rate is good, with 97% of traumatic amputees ambulating at 3 months. For dysvascular amputees, a study by Nehler et al showed prosthesis use at 17 months in 52% of patients with BKAs and 19% with AKAs. Despite aggressive rehab only 29% of surviving amputees were community ambulators, while the majority were household ambulators. Other factors, such as advanced age and multiple medical co-morbidities, also make prosthetic use and ambulation more challenging.
The additional energy cost for ambulation on level surface at self-selected speed is closely linked to the level of amputation, and impacts functional ability. Ambulation with a single trans-tibial prosthesis takes an additional 20-40 % energy, while trans-femoral prosthesis may be as much as 60% additional energy cost. Ambulation with hip dis-articulation prosthesis costs upwards of 100% additional energy. Bilateral trans-tibial amputation and single trans-femoral amputation have similar additional energy costs. Patients with traumatic amputations tend to have lower additional energy cost for ambulation, based on a relative lack of medical co-morbidities and likely a higher level of pre-morbid function.
Social role and social support system
Counselling for coping skills should be referred to appropriately trained social services or psychology services. Review of the existing social support system, home environment, and other caregiver options should be included. Peer-to-peer communication from community-based amputees is often a valuable resource and reassurance to the new amputee.
Quality of life and safety are maximized after amputation by achieving independence in mobility and self-care, with or without a prosthesis. Restoring access to the patient’s support system and/or community-based activities helps to build self-esteem and self-worth.
3. REHABILITATION MANAGEMENT AND TREATMENTS
Goals of care
Overall goals of care include:
- Prepare the patient for highest possible level of independent mobility and self-care
- Prepare the residual limb for prosthetic fitting and training, and
- Prevent complications (infection, contractures, weakness, falls) which may delay mobilization and prosthetic fitting.
Timeline of care lower limb amputation:
- Pre-op consultation with Physiatry
- Post-op day 1-5 = Acute care hospital with physiatry consultation if not already done in the pre-op phase.
- Post-op day 6-21 = Pre-prosthetic program which includes wound care, and evaluation and training for assistive devices and assistive equipment. This can occur in in Acute Rehab programs, Subacute Rehab units or in the Community setting with outpatient or home health services as appropriate.
- Post-op day 21-28 = follow-up with surgeon to confirm wound healing and Suture/staple removal.
- Post-op day 28+ = Casting for preliminary prosthesis while pre-prosthetic program continues.
- Post-op day 42+ = Fitting of preliminary prosthesis. Prostheses can be extremely expensive and it is important to obtain interdisciplinary input including medical, prosthetics and therapy teams to ensure the most appropriate prescription and reduce unnecessary expense related to incorrect prescription.
Patient-centered, goal-oriented, transdisciplinary, integrated, intensive and comprehensive rehabilitation is the gold standard for amputation rehabilitation. The true amputation rehabilitation “team” approach works best when all the team members evaluate the patient together or within a close time period, and then communicate closely and work collaboratively to develop a comprehensive treatment plan. When the patient is in the acute care hospital setting, the team may be smaller and may include only physiatry, physical therapy, occupational therapy, social service, and the patient. Once the patient enters a rehabilitation facility, then other team members (prosthetist, psychologist, pedorthotist) should be brought in to contribute to the ongoing management and treatment. As the team leader, the physiatrist should coordinate and supervise the care provided by the other team members. Prescriptions for therapies, assistive devices and adaptive equipment, testing, consultations, prosthetic devices, and pain medications should all be coordinated by the physiatrist. Weekly team meetings are recommended while the patient is in any inpatient setting to review and revise the treatment plan. Once the patient is in the outpatient setting, then team meetings or communication can take place less frequently. Long-term coordination of the care should remain the responsibility of the physiatrist.
Patient & family education
Education of the patient and family is a critical role of the physiatrist. The patient should be reassured about autonomy in decision-making and the team’s support of those decisions. The physiatrist should also explain the amputation etiology, risk factors, pre-prosthetic and prosthetic fitting and training timeline. The physiatrist and prosthetist should show samples of prosthetic devices and explain how they are made and used by the patient. Realistic goals for mobility, and return to home and community-based activities, should be established early to avoid misconceptions and false hopes. The team should provide patient-oriented literature to support and reinforce rehabilitation strategies.
Specific Care Treatments:
Skin healing and limb shaping take approximately three months. Overall goals include edema control, protection from trauma and monitoring for infection/ischemia. This pre-prosthetic period is managed with either immediate post-operative prosthesis (IPOP) or, more commonly, with compression dressing, beginning immediately after surgery. Compression options include a figure-8 wrap technique or removable rigid dressing. Compression wraps should be in place 24 hours per day, and re-wrapped at least twice daily. Non-adherent dressing should be placed directly over the surgical site under the compression wrap.
The residual limb should be elevated on a leg board when the patient is in the seated position to avoid dependent edema. After the sutures or staples are removed, a shrinker sock is commonly used instead of the compression wraps. Use of the shrinker sock should continue until the residual limb shape stabilizes (commonly 3-6 months). Lastly, ensuring good nutrition is essential for wound healing, so supplemental nutrition or nutrients should be considered in appropriate patients.
Hip and knee flexion contractures are frequent barriers for optimal outcomes and it’s extremely critical to take the appropriate measures to prevent contractures from occurring. In patients with pre-existing contractures, as mentioned in the rehabilitation section, it is often easier to stretch out tight or contracted hip flexors or knee flexors prior to amputation. To prevent contractures in post-operative patients, patients should be taught and educated on the importance of maintaining range of motion. Techniques include: prone time for >30 minutes daily, avoiding pillows under the healing leg, and early mobilization.
Pain control options should be clearly defined for both surgical site pain and phantom pain while remembering that amputees are still susceptible to other common pain generators as well (ex. Radiculopathies). Surgical pain is treated with both opiate and non-opiate medications, but tapered rapidly to avoid secondary complications. IV opioids are in general utilized for 2-3 days, followed by transition to long acting opioids plus PRNs. Careful monitoring for efficacy and side effects like constipation and confusion is important. Desensitization techniques can start a few days post-op, with tapping, massage and soft dressings. If generalized pain does not improve consider other etiologies for the pain including evaluation for wound infection, vascular disease. As the wound heals, trans-cutaneous lidocaine patches may be useful. Some phantom sensation is normal post-operatively in adult-acquired amputation and requires no special care, but painful or disturbing feelings from the phantom limb should be treated as phantom pain. Medication treatment options for phantom pain include neurotransmitter inhibitors, non-steroidal anti-inflammatory drugs, and acetaminophen. Non-medication treatments may include interventional modalities such as chemical ablation, radiofrequency ablation and non- interventional modalities such as transcutaneous electrical nerve stimulation (TENS), mirror box or imagery techniques, acupuncture, hypnosis, and others. In severe cases, pain specialists may consider spinal cord stimulators. The use of opiates for phantom pain should be avoided.
In addition to the above amputee-specific complications, new or acute exacerbations of chronic medical conditions can arise. Common complications include anemia, DVT/PE, infection, orthostasis. cardiac/pulmonary/renal issues. Each of these can affect participation and progress with therapies.
The rehabilitation program should start immediately after surgery to address bed mobility, transfers to wheelchair and toilet, progressive ambulation, stretching and strengthening of critical muscles in the upper and lower limbs, and maintaining range of motion (ROM) at hip and knee. The occupational therapy program should address self-care tasks (dressing, bathing, feeding, toileting) and adaptive equipment needs to achieve independence as soon as possible. Critical muscles in the upper limb (grip, triceps, pectoralis, latissimus) must be at least 4/5 strength to use an assistive device safely. Critical muscles in the lower limb (hip extensors and abductors, knee extensors, ankle dorsiflexors and plantarflexors) must also be at least 4/5 strength to hop with a walker initially, and then progress to prosthetic training. Progression to standing balance and partial weight bearing can potentially begin within a few days if there are no wound complications. Examples include a strap across the wheelchair and use of parallel bars with an adjustable footstool. Remaining rehabilitation should focus on accomplishing one-legged gait with assistive device, conditioning remaining limb segments and increasing endurance. In some cases, prehabilitation may be indicated. For example contractures can be addressed pre-operatively with a longer lever arm and without post-surgical pain, highlighting the importance of a pre-surgical physiatric exam and assessment.
Rehabilitation during and after acute hospital stay should include input from physiatry, social service, family and the patient. Issues to be considered include family support and availability at home, home accessibility for assistive devices, including wheelchair, transportation and IADLs like meal preparation options.
Independent mobility in the home and community is important for patient self-esteem. The use of a wheelchair may be necessary for outdoor and long distance mobility, but should be avoided in the home if possible. Higher level activities related to work, recreational sports, and driving may be addressed in both the pre-prosthetic and prosthetic phase as appropriate. If available, vocational rehabilitation can be integrated into the patient’s recovery and rehab plan to provide adaptation to current career or training for alternative careers.
Psychological adjustment to limb loss should be initially addressed by the physiatrist, and then further assessment by a psychologist can be incorporated as needed
To monitor progress with rehabilitation, physical measures include a 2-minute walk test and the L-test can be used. Satisfaction and outcome measures include M-PLUS, SF-36, OPUS
Translation into practice: practice “pearls”/performance improvement in practice (PIPs)/changes in clinical practice behaviors and skills
Opportunities for performance improvement in practice should be focused on early intervention by the physiatrist, and appropriate/timely referral to other professional services (physical therapy, occupational therapy, social services, prosthetist). Early mobilization of the patient will help to prevent both physical complications such as deconditioning, contractures, and falls, and medical complications such as decubitus ulcers, pneumonia, deep vein thrombosis (DVT), and bladder infections.
4. CUTTING EDGE/EMERGING AND UNIQUE CONCEPTS AND PRACTICE
Predictive tools are available to assist the physician in deciding whether to prescribe a prosthesis or not. The most studied of these tools is the Amputee Mobility Predictor (AMP-PRO). Other simpler strategies include assessing single limb stance or cardiac function. The most important information to help predict function with a prosthesis is the level of ambulation prior to amputation. Measurement of treatment outcomes in the peri-operative phase is of little value, and should be delayed until the prosthetic phase of care when mobility reaches a plateau.
Data in CHF and COPD show that accelerometry can predict and potentially prevent hospital re-admission. Increasing use in the amputation patient population might fill the critical gap and optimize determining prosthetic candidacy, appropriate prosthetic prescription and ongoing monitoring.
Cutting edge concepts and practice
Osseous-integration for lower-limb prosthetic attachment has been the goal for decades, but fraught with complications. It remains in the realm of cutting-edge and emerging technology, because it would eliminate the most challenging part of prosthetic fitting: the socket interface. Implantation of a metallic or ceramic strut into the remaining bone of the residual limb, with lower risk of infection, will make future prosthetic devices perform better and maximize patient mobility.
5. GAPS IN THE EVIDENCE-BASED KNOWLEDGE
Gaps in the evidence-based knowledge
Immediate post-operative prostheses (IPOP) have been described and used on a limited basis for decades. The functional outcome at six months appears to be the same, but patients are mobilized earlier, which has obvious physical and psychological benefits. Surgeons may choose conventional dressings over IPOP especially in vascular amputations because of the ability to monitor the surgical site.
The Ertl surgical procedure for trans-tibial amputation creates a bone bridge between the tibia and fibula, therefore making the residual limb more stable and potentially able to tolerate end-bearing. This procedure has also been described in the literature for decades, but has not gained wide popularity and is currently used by a limited number of physicians for selected cases only.
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- MacKenzie, Ellen J., Michael J. Bosse, Renan C. Castillo, et al. 2004 Functional Outcomes Following Trauma-Related Lower-Extremity Amputation. The Journal of Bone and Joint Surgery. American Volume 86–A(8): 1636–1645.
- Nehler, Mark R, Joseph R Coll, William R Hiatt, et al. 2003 Functional Outcome in a Contemporary Series of Major Lower Extremity Amputations. Journal of Vascular Surgery 38(1): 7–14.
- Ziegler-Graham, Kathryn, Ellen J. MacKenzie, Patti L. Ephraim, Thomas G. Travison, and Ron Brookmeyer 2008 Estimating the Prevalence of Limb Loss in the United States: 2005 to 2050. Archives of Physical Medicine and Rehabilitation 89(3): 422–429.
Original Version of the Topic
Heikki Uustal, MD. Peri-Operative Management. 04/05/2013
Courtenay Stewart, DO
Nothing to Disclose
Ninad Karandikar, MD
Nothing to Disclose