Amputee

Rehabilitation
Demographics &
Etiology
 Demographics & Etiology
Lower Extremity Amputation
Main Causes of Lower Extremity
Amputation
1. Disease (Cancer)
2. Trauma
3. Congenital
 Demographics & Etiology
Lower Extremity Amputation
#1 Cause of Amputations  Disease
Diabetes Mellitus (DM) : grangrene
Peripheral Vascular Disease (PVD) : also know as intermittent claudication. Vessels
are narrowed or blocked (arteriosclerosis , embolism, clots, ..)
Chronic Venous Insufficiency (CVI) : the wall and/or valves veins are not
working effectively
difficult blood return to heart stasis
Malignant tumors : osteosarcoma, melanoma
Potentially lethal sepsis
Diabetes
• According to the Centers for Disease Control and Prevention, in 2009 there were
68,000
amputations due to complications from it

• 25% mortality 1 year after amputation.

• 50% mortality 3 years after amputation. diabetes
 Demographics & Etiology
Lower Extremity Amputation
#2 Cause of Amputations  Trauma

Severe trauma
Burns
Frost bite

Leading causes of trauma:

40.1% - Machinery
27.8% - Powered tools and appliances
8.5% - Firearms
8% - Motor Vehicle Crashes
Demographics & Etiology
Upper Extremity Amputation

Incidence
• Less than 5% of all amputations are UE
amputations

Etiology
• 90% Trauma
• 5% Congenital
• 5% Other
Terminolo
gy
 Terminology
Amputatio
n

Trans:
• Whe
n the
ampu
tatio
n is
acros
s the
axis
of a
long
bone
Terminology

Sound Limb
• The healthy limb

Residual Limb (stump)

• The extremity of a limb left after amputation
ISO Standard Nomenclature for the Upper and lowe limb
 Partial Foot Amputation
Toe Amputation
• Excision of any part of one or more of the toes

Toe Disarticulation
• At metatarsophalangeal joint
• May result in biomechanical deficiencies:
• Amputation of Great Toe
• 2nd Digit Amputation
 Symes: patient can still put
weight on his leg even without
prothesis

Chopart to preserve the

hindfoot

LisFranc to preserve the

midfoot

Transmetatarsal to preserve
the forefoot
 Below Knee Amputation
Transtibial Amputation

• Amputation through the tibia (and

fibula)
Knee Disarticulation
• Amputation through the knee joint
• Offers good weight distribution ability and
retains a long, powerful femoral lever arm
• Yields a non-cosmetic socket due to need
for external joint mechanism

Supracondylar Amputation
• Patella is left for better end weight-
bearing
• Area between end of femur and
patella may delay healing
Above Knee Amputation 
Transfemoral Amputation

• Amputation through the

femur
Hip Disarticulation
• Uncommon
• Involves loss of all of the femur
• Usually done in cases of malignant
tumors, extensive gangrene,
massive trauma, or advanced
infection
 Hemipelvectomy  Transpelvic
Amputation
• Uncommon
• Involves loss of any part of the ilium, ischium, and pubis
• Usually done in cases of malignant tumors, extensive
gangrene,
massive trauma, or advanced infection
Upper Extremity Amputations
• Partial Hand Amputation

Levels of partial hand

amputation:

1.Transphalangeal; thumb
spared.

2. Thenar partial or
complete.

3. Transmetacarpal, distal;
thumb spared or involved.

4.Transmetacarpal, proximal;
thumb spared or involved.
Upper Extremity
Amputations
• Partial Hand Amputation
Upper Extremity Amputations
• Wrist Disarticulation
• Amputation through the wrist
joint
Upper Extremity Amputations
• Transradial Amputation
• Amputation through the radius (and
ulna)
Upper Extremity Amputations
• Elbow Disarticulation
• Amputation
through the
elbow joint
Upper Extremity Amputations
• Transhumeral
Amputation

-Amputation
through the
humerus
Upper Extremity
Amputations
• Shoulder Disarticulation
Surgical
Considerations
Surgical Considerations
Level of amputation should consider:
◦ Disease process
◦ Viability of tissues
◦ Prothesis available
 Surgical Considerations
• Amputation is a reconstructive operation

• Pre-operative planning is essential

• Surgical Objectives:
• Remove all diseased and damaged anatomy
• Construct a residual limb that functions: a stump too short
may tend to slip out of the prothesis
• Preserve as much functional length as possible
Surgical Considerations

Amputations should be performed at the most distal site compatible

with wound healing to achieve the optimal potential for ambulation
 Surgical Considerations
• The residual limb should have sufficient soft-tissue coverage to resist
the shear forces involved in prosthetic ambulation

• Bevel bone ends (naturally curved ends)

• Balance muscle forces
• Perform Myodesis - suturing the muscle or tendon to bone
• Perform proximal nerve resection – stretch &
severe nerves, decreases incidence of neuromas
Surgical
Considerations
• Bevel bone
ends
Surgical Considerations
• Metal titanium
permanently
incorporated into the bone
Qualities of an ideal stump:
 Should heal adequately
 Should have rounded, gently contour with adequate muscle padding
 Should have sufficient length to bear prothesis
 Should have thin scar which does not interfere with the prothesis
function
 Should have adequate adjacent joint mvt
 Should have adequat blood supply
Complications
Early:
◦ Haemorrhage
◦ Haematoma
◦ Infection

Late:
◦ Depression (shock, denial, deep sadness and anger, acceptance)
◦ Stump ulceration
◦ Flap necrosis
◦ Painful scar
◦ Phantom limb/ pain
◦ Joint stiffness
◦ Osteomyelitis
◦ Osteoporosis and tendance to fracture.
Phases of Amputee
Rehabilitation
 Who is on the TEAM?
• PATIENT
• Patient Support System/Caregivers
• MD
• PT
• Prosthetist
• OT
• Nursing
• Psychology
• Dietician
 What are the responsibilities of the team?
• Evaluate the patient
• Ensure medical stability of the patient
• Prepare the patient for life as an amputee
• Prescribe prosthesis (if appropriate)
• Fabricate prosthesis
• Evaluate fit of prosthesis
• Educate the patient on use of and care of prosthesis
• Follow-Up care for the patient
• for maintenance, problems, changing status, need for different
equipment
Rehabilitation program can be divided into :
1. Pre-amputation phase
2. Immediat post-surgical phase
3. Pre-prothethic training phase
4. prothethic training phase
5. Patient education
6. Life-long management and follow up
 Pre-Amputation Phase
• Primary Goal: Education & Prevention!
• Educate:
• Reinforce realistic expectations
• Explain sequence of upcoming events
• Answer any questions
 Immediate Post Surgical Phase
• Goals
• Ensure medical stability/ pain control
• Promote wound healing
• Reduce edema
• Prevent loss of motion
• Increase UE and LE strength
• Promote mobility and self-care
• Promote sound limb care
• Assist with limb loss adjustment
• Emotional support
• EDUCATE, EDUCATE, EDUCATE!
• Where?
• Acute Care Hospital
 Pre-Prosthetic Training Phase
• Goals
• Continue healing without complications
• Continue to manage edema
• Maintain ROM
• Continue with increasing UE and LE strength
• Continue with promoting mobility and self-
care
• Promote sound limb care
• Assist with limb loss adjustment
• Order prosthesis (if/when appropriate)
• EDUCATE, EDUCATE, EDUCATE!
 Pre-Prosthetic Training Phase
• Where?
• Acute Care Hospital, In-Patient Rehab, SNF, Home, Outpatient
Rehab

• Post-Amputation Placement
• Inpatient Rehabilitation – 36%
• Skilled Nursing Facility – 35%
• Outpatient Rehabilitation – 27%
• Home – 2%
 Prosthetic Training Phase
• Goals
• Continue to manage edema
• Continue with increasing UE and LE strength
• Continue with promoting mobility and self-care
• Incorporate use of prosthesis into all activities
• Maintain skin integrity
• Promote sound limb care
• Assist with limb loss adjustment
• EDUCATE, EDUCATE, EDUCATE!
• Where?
• In-Patient Rehab, SNF, Home, Out-Patient
Rehab
Amputee
Education
 Education
• Post-Op Complications
• Sound Limb Care
• Residual Limb Care
• Prosthetics
• Prosthetic Components &
Prescription
• Skin Integrity
• Sock Management
 Post-Op Complications
• Pulmonary Complications
• DVT
• Delayed Wound Healing and
Infection
• Contractures
• Physical Deconditioning
• Pain
 Sound Limb Care
• Daily Skin Inspection
• Systematic Inspections
• Attention to bony prominences
• Attention to problem areas
• Ensure patient can see feet

• Inspect the Foot

• Toe Nails: Broken, Cracked, Sharp Nails
• Broken Skin: Between Toes, Sides of Feet, Top and Ends of Toes and Soles
of Foot
• Soft Toe Corns: Check Between Toes
• Callus: Check for Cracks
• Drainage: Check Socks
• Odor: Unusual Odors from Any Part of Foot
 Sound Limb Care
• Skin Cleansing
• Routine on a daily basis, if soiled, after exercise
• Avoid hot water
• Use mild cleaning agents, Avoid perfumed soaps

• Minimize Negative Environments

• Low humidity  Dry skin
• High humidity  Damp skin
• Avoid extreme hot and cold surfaces without proper footwear
• Minimize skin exposure to excessive moisture (Perspiration, Wet weather,
Wound drainage, Incontinence) however maintain adequate moisture (Reduce
friction, Hydrate skin, Maintains tissue elasticity)
 Sound Limb Care
• Footwear
• NEVER walk barefoot
• Dry Cotton or Wool Socks, White Preferred
• Inspect shoes for tacks, nails, rocks
Residual Limb Care
Goal:

To prepare the residual limb for prosthetic usage, while providing
protection to the incision and limb and maintaining an optimal
environment for wound healing.
Residual Limb Care
• Pain
• Edema Management/Limb Shaping
• Contracture
Prevention/Positioning
• Strengthening/HEP Development
 Pain
85% of all amputees experience phantom sensation, phantom pain
or
residual limb pain.
Pain
• Phantom Sensations
• Sensations perceived as originating from
the amputated limb
• Phantom Pain
• Sensations of pain perceived as
originating from the amputated limb
• Residual Limb Pain
• Pain originating from the intact extremity
Pain
Phantom Sensation Phantom Pain Residual Limb Pain

Touch Dull Aching Prosthetic

Pressure Burning Neuroma
Cold Stabbing Knife-Like Sympathetic
Wetness Sticking, Squeezing Referred
Itching Electrical Shocks Abnormal Tissue
Formication Leg is Being Pulled Joint Pain
Fatigue Off Trauma Related Bone Pain
General Pain Pain Pre-Operative Soft Tissue Pain
Telescoping Pain Unnatural Residual Limb Changes
Limb Positioning
Phantom
Movement
 Pain
Treatment for Neuroma
Neuroma formation is a natural repair phenomenon that
occur when a peripheral nerve is transected
Pain occurs when the neuroma is situated at the end of
the residual limb or at a pressure point in the prothesis.
Non operative treatment: local analgesics or
corticosteroids
Surgical excision: of the neurome is the treatment of
choice
Pain
Treatment for Phantom Pain
• Analgesics • Psychological
• Surgery Interventions
• Acupuncture • Sensory
• Electric Overload
Stimulation • Mirror
Therapy Therapy
• Vibration
Therapy
• Ultrasound
Mirror therapy
Form of motor imagery in which a mirror is used to
convey visual stimuli to the brain through observation
of one’s unaffected body part as it carries out a set of
movements.
 Edema Management/Limb Shaping
• 4 Main Functions of Residual Limb Management Techniques:
1. Volume containment, Edema reduction
2. Shaping
3. Protection
4. Desensitization

͞Dog Eaƌs͟
Edema Management/Limb Shaping
• Immediate Post-Operative Prosthesis (IPOP) 3 – 6 weeks

•Post-Operative Dressing Selection

• Soft Dressings 6 – 8 weeks
• Elastic Wrap
• Shrinker
• Semirigid Dressings
• Rigid Dressings
• Non-removable rigid dressing
• Removable rigid dressing
Edema Management/Limb Shaping
Elastic Wrap
• Advantages
• Can assist in shaping limb
• Low cost
• Wound accessibility
• Easy to apply with some patients
• Can be laundered
• Disadvantages
• Must be reapplied every 2 hours for edema
control
• Can be difficult to apply
• Tourniquet may result if applied improperly
• Can slip off limb with exercise or mobility
Edema Management/Limb
Shaping
Stump Shrinkers
- it is important that the pressure be
greater at the end and lessens
gradually towards the tight
 Edema Management/Limb Shaping
Shrinker
• Advantages
• Can be easily applied
• Wound accessibility
• Graded pressure (high to
low) from distal to
proximal
• Disadvantages
• May cause incision if applied
improperly
• May be too painful to apply
and wear immediately post-
 Contracture Prevention/Positioning

Contracture
• A condition of shortening and/or hardening of muscles, tendons,
or other tissue, often leading to deformity and rigidity of joints.
 Contracture Prevention/Positioning
• Transtibial
• Contractures: Knee Flexion, Hip Flexion, Hip ABDuction, Hip
External Rotation
AVOID THESE!

• Things to do: Prone Lying, Knee

Extension Board on Wheelchair, Knee
Extension Brace
 Contracture Prevention/Positioning
• Transfemoral
• Contractures: Hip Flexion, Hip ABDuction, Hip
External Rotation
AVOID THESE!

• Things to do: Prone Lying

Strengthening
• LE
AROM/AAROM/PROM
• Strengthening
• Balance & coordination
• Endurance
• Mobility
Muscle strength
For transfemoral amputation:
Hip extensors & abductors are needed

For transtibial amputation:

Hip extensors & abductors
Knee flexors & extensors are needed
 Current Prosthetic
Management
An Overview of Upper and Lower Extremity Fitting
Processes, Designs and Componentry
Outcomes Based Practice

• Success is measured by
the patients ability to
reintegrate into their
pre- amputation quality
of life
• Physically
• Psychologically
• Socially
Parts in lower limb prosthetic
 What Determines Socket Design?
• PATIENT!!!
• Potential activity level
• Skin condition
• Patient’s pre-amputation lifestyle
• A transtibial should be able to return to
the same level of mobility prior to
amputation
• SOCKET FIT and patient care management
is critical
 Types of Prosthetic Designs
• Immediate Post-Operative Prosthesis (IPOP)
• Success depends on the skills/coordination of the
clinic team
• Preparatory Prostheses
• Frequently used for several weeks or months
until the residual limb has stabilized before
the definitive prosthesis is provided.
• Energy efficient foot modules, knees not utilized
• Definitive Prostheses
• Design is based on short term AND long
term goals
• 30% cost savings by going directly to
definitive
prosthetic design1
 Types of Prosthetic Designs
• Preparatory Prosthesis
• First Prosthesis (3-6 months)
• Prosthesis is comprised of basic componentry
• Allows patient to rehab, integrate into
daily routine and complete ADLs
• With proper prosthetic care, patient will
reach the potential of the preparatory
prosthesis before reaching their individual
prosthetic potential
 Types of Prosthetic Designs
• Definitive Prosthesis
• Design is based on the not
only the short term goals but
long term goals as well
• Benefits of utilizing
flexible inner
• Comfort
• Adjustability
• Relieve Bony anatomy
• Volume change
 Transtibial Socket Design

Patellar Tendon Bearing (PTB) Total Surface Bearing

• Loads specific weight-bearing • Loads uniformly and
areas and relieves non- indiscriminately
weight bearing areas
• Total Contact • Total Contact
• Lack of transverse plane
control
due to cylindrical design
• Suspension is the primary
mechanism of transverse
plane control
Transtibial Socket Design
 TransFemoral (TF) Socket Design
Narrow M/L Ischial Containment Socket Quadrilateral Socket

Ischium contained within the socket Ischium sits on a shelf

Custom Shape Not a true custom shape

Indicated for a majority of wearers Indicated for previous

wearers/patient preference
 TF Socket Design

Ischial Containment Design Quadrilateral Design

 Ischial Containment Socket
• Advantages • Disadvantages
• Increased Skeletal Control • High proximal trim lines
• Intimate proximal trim lines • Ant/Post trim lines limits
• Increased proximal weight- ROM while sitting
bearing • Posterior proximal trim lines
• Can be contoured for specific can impede sitting comfort
anatomical control and • Specifically loaded soft tissues
weight bearing are
stressed
Subischial Socket Design
• Advantages • Disadvantages
• Pressure management
• Uniform loading of tissues
• Decreased stress on soft tissues • Problem solving (seal)

• Positive suspension
• Coronal plane control while
• No inherent pistoning ascending and descending stairs
is more demanding
• Increased ROM while sitting

• NEW
• Increased demand to utilize existing • Lack of long term subject and
musculature objective experience
• Comfort
• Increased demand to utilize
existing

Subischial Socket
 Hip Disarticulation
(HD)/HemiPelvectomy
• Very Involved Fitting
and
Rehab Process
• High rate of non-
prosthetic users
• Never given an
opportunity to
try
• Poor socket
comfort
• High energy
expenditure
 HD/ HemiPelvectomy Socket Design
• New materials have allowed
for more comfortable
socket designs
• Utilizes a silicone liner
between the skin and socket
frame
 Hip Joints
• Hydraulic monocentric hip
joint
• Helix Hip Joint
• Hydraulic multi plane hip joint
• Littig Hip™
• Modular Hip Joint
• Extension Assist
 Suspension
• Pin Locking
• Clutch lock, rachet
lock, friction lock
• Suction with Sleeve
Suspension
• Elevated Vacuum
 Prosthetic Feet
• Solid Ankle Cushion Heel (SACH)
foot
• Single Axis
• Multiaxial
• Dynamic Response
• Multiaxial Dynamic Response
• Vertical Shock
• Microprocessor
 Microprocessor ankles
• Swing Phase only Microprocessor
ankles
• Ossur Proprio
• Ottobock 1C66
• Endolite Elan
• Powered Propulsion
Microprocessor
ankle
• Bionx BiOM
 Benefits of Microprocessor Ankles
• Decreased Energy Expenditure
• Increased Gait Symmetry while
negotiating Stairs and Ramps
• Reduce Stress on other Joints
• Increased Stability/Safety
negotiating uneven terrain