When amputation is elective, certain preparatory measures can help optimize recovery. It is important to educate the patient and family members as early as possible regarding the necessity of amputation and to review the entire process from preoperative preparation to prosthetic fitting and living with a prosthesis. Such education helps increase the patient's commitment to the process, which is essential to a successful outcome, and also maximizes family support. Meeting with a peer counselor who has had an amputation can be helpful for the patient.
Preoperative Management
Preoperative management includes
Functional assessment
Planning
Exercise program
A functional assessment evaluates patients' current capabilities along with their goals. Using the functional assessment, the surgeon, prosthetist, and physical therapist formulate a preoperative and postoperative plan.
Regardless of age and current physical status, patients should begin a general and specific exercise program as soon as possible preoperatively and continue exercising postoperatively. Exercises to maintain or increase muscle strength, flexibility, and range of motion are taught by a physical therapist. The stronger and more flexible patients are, the more they can do with or without their prosthesis. An occupational therapy program can be implemented when difficulties doing daily activities are anticipated.
Postoperative and Preprosthetic Considerations
Postoperative management goals are to
Protect the residual limb from accidental trauma (eg, bumping, falls)
Control edema
Promote healing
Maintain strength, cardiovascular endurance, and joint range of motion
There are many dressing options to protect the residual limb and control edema. Effective management of edema increases circulation, promotes healing, and reduces severity of postoperative pain and phantom limb pain.
A physical therapist will work with the patient before and after hospital discharge as needed based on the patient's abilities and specific amputation. Training may include standing balance, walking in parallel bars, use of a walker, crutches, and/or wheelchair, and self-care skills including transfers and personal hygiene.
The prosthetist will see the patient weekly to monitor progress and residual-limb readiness for fitting a preparatory prosthesis, which is done when residual-limb fluid volume is reasonably stable.
Preparatory prosthesis
When the residual limb has healed and fluid volume has reached an initial level of stability—usually 6 to 10 weeks postoperatively, but longer if there are complications—a preparatory prosthesis can be fitted. A preparatory prosthesis is a temporary prosthesis that allows progressive weight-bearing and switching of components to match patients' changing functional requirements as they become accustomed to walking and doing other activities. The socket of the preparatory prosthesis may need to be refit several times during this period.
In addition to improving mobility and independence, advantages of early prosthesis fitting include achieving better acceptance of the amputation, restoring body image, reducing phantom limb pain, increasing proprioception and phantom limb sensation, and hastening maturation of the residual limb.
The residual limb of adults continues to undergo considerable volume and shape change for 12 to 18 months after amputation. At this time the preparatory prosthesis can be exchanged for a permanent or definitive prosthesis, which often uses the same joint and appendage components that were identified as optimal during the preparatory phase. However, even after a residual limb is considered mature (> 18 months postamputation), residual-limb fluid volume will continue to fluctuate daily and long-term. The magnitude of change varies among individuals and can be problematic.
Learning to use a limb prosthesis
The patient initially learns how to function with a prosthesis during the fitting process. The process involves several appointments to achieve acceptable levels of comfort and stability.
For patients with an upper extremity prosthesis, once comfort and stability are achieved, the prosthetist works to provide maximum functional capacity with appropriate spatial positioning of joints and appendages. An occupational therapist then works with the patient to optimize function for the patient’s specific daily activities.
For patients with a lower extremity prosthesis, once residual limb comfort and stability are achieved, a prosthetic hip, knee, ankle, and/or foot is introduced to achieve balance and posture (see also Leg Amputation Rehabilitation). The patient initially begins ambulation within parallel bars. The prosthetist ensures that sufficient biomechanical efficiency is achieved before the patient is seen by the physical therapist for gait training. As the patient learns to ambulate effectively, the prosthetist will modify the socket to compensate for morphologic changes in tissues and in biomechanical alignment of joints and appendages. In addition, as the patient acclimates and is able to ambulate more aggressively, the prosthetic hip, knee, ankle, and/or foot may require changes to provide optimal, efficient ambulation and function.
Counseling or psychotherapy may help when patients have prolonged difficulty adjusting to the loss of their limb and to prosthetic use.
