Before amputation, the physician describes to the patient the extensive postsurgical rehabilitation program that is needed. Psychologic counseling may be indicated. The rehabilitation team and the patient decide whether a prosthesis or a wheelchair is needed. (See also Overview of Rehabilitation and Limb Prosthetics.)
Rehabilitation teaches ambulation skills; it includes exercises to improve general conditioning and balance, to stretch the hip and knee, to strengthen all extremities, and to help patients tolerate the prosthesis. Because ambulation requires a 10 to 40% increase in energy expenditure after below-the-knee amputation and a 60 to 100% increase after above-the-knee amputation, endurance exercises may be indicated. As soon as patients are medically stable, rehabilitation should be started to help prevent secondary disabilities. Older patients should begin standing and doing balancing exercises with parallel bars as soon as possible.
Flexion contracture of the hip or knee may develop rapidly, making fitting and using the prosthesis difficult; contractures can be prevented with extension braces made by occupational therapists.
Physical therapists teach patients how to care for the residual limb and how to recognize the earliest signs of skin breakdown.
Residual Limb Conditioning and Prostheses
Residual limb conditioning refers to the process of preparing the residual limb in anticipation of use of a prosthesis and includes skin care, physical therapy, and pain management. These measures help promote the natural process of shrinking that must occur before a prosthesis can be used (see Preparing for Limb Prosthesis). After only a few days of conditioning, the volume of the residual limb may have shrunk greatly. An elastic shrinker or elastic bandages worn 24 hours/day can help taper the residual limb and prevent edema (see Edema of the Residual Limb). The shrinker is easy to apply, but bandages may be preferred because they better control the amount and location of pressure. However, application of elastic bandages requires skill, and bandages must be reapplied whenever they become loose.
Early ambulation with a temporary prosthesis helps in the following ways:
Enables the patient to be active
Accelerates residual limb shrinkage
Prevents flexion contracture
Reduces phantom limb pain
The socket of the pylon (the internal framework or skeleton of a prosthesis) should fit the residual limb snugly—made possible by modern computerized design and manufacturing processes. Various temporary prostheses with adjustable sockets are available. Patients with a temporary prosthesis can start ambulation exercises on the parallel bars and progress to walking with crutches or canes until a permanent prosthesis is made.
The permanent prosthesis should be lightweight and meet the needs and safety requirements of the patient. If the prosthesis is made before the residual limb stops shrinking, adjustments may be needed. Therefore, manufacture of a permanent prosthesis is generally delayed a few weeks until shrinkage stops. For most older patients with a below-the-knee amputation, a patellar tendon-bearing prosthesis with a solid-ankle, cushion-heel foot, and suprapatellar cuff suspension is best. Unless patients have special needs, a below-the-knee prosthesis with thigh corset and waist belt is not prescribed because it is heavy and bulky. For people with above-the-knee amputations, several knee-locking options are available according to the patient’s skills and activity level. Some newer technologies include microprocessor-controlled knee and ankle joints that enable patients to adjust movement as needed.
Care of the residual limb and prosthesis
Patients must learn to care for their residual limb (see Skin Care of the Residual Limb). Because a leg prosthesis is intended only for ambulation, patients should remove it before going to sleep. At bedtime, the residual limb should be inspected thoroughly (with a mirror if inspected by the patient), washed with mild soap and warm water, and dried thoroughly. Patients should consult with a clinician or prosthetist before treating any of the following possible problems:
Excessive sweating: An unscented antiperspirant may be applied.
Inflamed skin: The irritant must be removed immediately, and powder or a low-potency corticosteroid cream or ointment should be applied.
Broken skin: The prosthesis should not be worn until the wound has healed.
The residual limb sock should be changed daily, and mild soap may be used to clean the inside of the socket. Standard prostheses are neither waterproof nor water-resistant. Therefore, if even part of the prosthesis becomes wet, it must be dried immediately and thoroughly; heat should not be applied. For patients who swim or prefer to shower with a prosthesis, a prosthesis that can tolerate immersion can be made.
Complications
Residual limb pain is the most common complication (see Pain in the Residual Limb). Common causes of pain include
A poorly fitted prosthetic socket: This cause is the most common.
Neuroma: An amputation neuroma is usually palpable. Treatments include ultrasound therapy, injection of corticosteroids or analgesics into the neuroma or the surrounding area, cryotherapy, and continuous tight bandaging of the residual limb. Surgical techniques are available for refractory pain.
Spur formation at the amputated end of the bone: Spurs may be diagnosed by palpation and x-ray. The only effective treatment is surgical resection.
Phantom limb sensation (a feeling that the amputated part is still present possibly accompanied by tingling) is experienced by some people with recent amputations. This sensation may last several months or years but usually disappears without treatment. Frequently, patients sense only part of the missing limb, often the foot, which is the last phantom sensation to disappear. Phantom limb sensation is not harmful; however, patients, without thinking, commonly attempt to stand with both legs and fall, particularly when they wake at night to go to the bathroom.
Phantom limb pain
Skin breakdown tends to occur because the prosthesis presses on and rubs the skin and because moisture collects between the residual limb and prosthetic socket. Skin breakdown may be the first indication that the prosthesis needs adjustment and needs to be managed immediately. The first sign of skin breakdown is erythema; then cuts, blisters, and sores may develop, the prosthesis is often painful or impossible to wear for long periods of time, and infection can develop. Several measures can help prevent or delay skin breakdown:
Having an interface that fits well
Maintaining a stable body weight (even small changes in weight can affect fit)
Eating a healthy diet and drinking lots of water (to control body weight and maintain healthy skin)
For patients with diabetes, monitoring and controlling their blood sugar level (to help prevent vascular disease and thus maintain blood flow to the skin)
For patients with a lower-limb prosthesis, maintaining body alignment (eg, wearing only shoes with a similar heel height)
However, even with a good fit, problems can occur. The residual limb changes in shape and size throughout a day, depending on activity level, diet, and the weather. Thus, there are times when the interface fits well and times when it fits less well. In response to such ongoing changes, people can help maintain a good fit by switching to a thicker or thinner liner or sock, by using a liner and a sock, or by adding or removing thin-ply socks. But even so, the residual limb’s size may vary enough to cause skin breakdown. If there are signs of skin breakdown, patients should promptly see a health care professional and a prosthetist; when possible they should also avoid wearing the prosthesis until it can be adjusted. (See also Loosening of the Prosthesis.)
