A 38 y/o Female with Unilateral Trans-Tibial Amputation: Amputee Case Study
A 38 y/o Female with Unilateral Trans-Tibial Amputation
The following is a case presentation of a 38 year-old female who underwent trans-tibial amputation as a result of lower limb ischemia. The individual was treated in an acute rehab facility for 9 days prior to returning home with family support. Therapy in this setting was centered around pre-prosthetic training including wheelchair mobility, limb care and desensitization, transfers, pre-prosthetic ambulation and therapeutic exercise. Based on the patient's presentation, age and prior level of function, it is anticipated that she will be a functional ambulator with the use of a prosthesis.
trans-tibial, ischemia, amputation, pre-prosthetic rehabilitation
The patient is a 38 year-old female who presented to acute rehab status post right trans-tibial amputation resulting from lower limb ischemia. The patient reported a history of lower leg pain lasting 1-2 weeks and presented to an emergency room for treatment. A femoral-popliteal bypass graft was performed, however the limb could ultimately not be salvaged. The patient presented to acute rehab 11 days after admission to the hospital. The hospital stay was complicated by symptoms of alcohol withdrawal, depression and anxiety.
It was determined that the patient had a hyper-coagulable blood disorder, which was a contributing factor to the ischemia. The patient is also a smoker and a heavy alcohol user and reported drinking 2+ pints of vodka daily.
Prior to the amputation, the patient was independent with mobility and ADLs. She was able to drive although she did not have a vehicle. The patient was unemployed however was attending a trade school for cosmetology and is a single mother to a 7 year-old daughter.
At the time of admission to rehab, the patient reported they had not yet had to look at or touch their residual limb. They reported phantom limb and residual limb pain rated at 3/10 at rest and up to 8/10 with dependent positioning and gentle palpation.
The circumferential measurements at the right tibial tubercle were 2.25 cm greater than that of the left leg. The distal end of the residual limb was slightly dog-eared with a circumference visibly greater than at the tibial tubercle. The incision was noted to be well approximated with staples in place and with minimal, non-odorous serous drainage. The distal end of the residual limb was also noted to have a boggy quality indicating presence of edema.
The patient demonstrated full muscle strength in the left lower extremity and in the right hip flexors, extensors and abductors. Right knee extension and flexion strength testing were considered inconclusive secondary to pain, although the patient was able to perform 0-110 degrees of action motion at the aforementioned joint. No joints of the lower extremities demonstrated range of motion limitations.
Upon evaluation the patient was able to complete bed mobility with the use of a bedrail, and to complete stand pivot transfers with standby assistance. Ambulation with a FWW was limited to 12 feet secondary to pain and nausea.
It was predicted that the patient would be able to use a front wheeled walker for household mobility and a custom wheelchair for community mobility until she was ready to be fit with a prosthesis, at which time she would use it for primary locomotion. It was also predicted that the patient would require some support from family upon discharge to assist in her transition back to the community but that she would ultimately be able to return to her own residence and return to her role as a mother and student.
The patient demonstrated high motivation to return to her prior level of function, however she also reported anxiety, depression and isolation as a result of her amputation. She was also reluctant to observe and touch her residual limb because of the associated emotional and physical pain. Therefore a primary obstacle to successful rehabilitation was a lack of emotional and spiritual support.
Pain was also a barrier to increasing ambulatory distances and to standing for extended periods, and therefore had the potential to interfere with the patient's community participation and personal roles.
In an effort to decrease pain and prepare the patient for use of a prosthetic limb, the patient was educated on and then observed performing desensitization strategies at least three times per day. She was taught how to perform her own dressing changes, how to manage her rigid removable dressing and also how to observe her residual limb for changes in volume and skin quality. Because dependent positioning of the limb was also painful, the patient was also instructed to remove the rigid removable dressing prior to standing or ambulation and perform several rounds of knee and hip flexion and extension to improve circulation and delay onset of pain secondary to increased volume in the distal portion of the residual limb.
To address the psychological aspect of the patient's condition, a psychiatrist was consulted, who also provided resources on alcohol cessation. In addition, the patient was connected with a local amputee support group through which she was able to meet other amputees of similar age and etiology and received information on activities and resources that were available to her, as well as an opportunity to share her feelings and experiences with an individual with first hand knowledge.
The patient was in fact able to discharge to her mother's home and plans to return to her own home in approximately two weeks. She was able to increase her ambulation distances to 100-120 feet consistently using a FWW and her pain was reduced from an average 8/10 upon admission to an average 3/10 at discharge. She was able to stand for periods of 7-10 minutes to complete ADLs without increased pain. The patient also reported less aversion to her residual limb and greater hope for the future. She stated that she planned to remain sober with the help of a community outreach program she learned about during her psychiatric evaluation. At the time of discharge, the patient's staples remained in place and therefore she was not appropriate for prosthetic fitting. The surgery team at this facility does not advocate the use of early walking aids.
This case was unique in this facility as it involved a relatively young patient who had a few comorbidities. The primary concerns regarding her medical condition and potential for recovery are her hyper-coagulable blood disorder and her chronic alcoholism.
Although it remains to be seen if this patient will ambulate with a prosthesis, Nehler et al. reports that nearly half of all patients with a BKA in this age group will ambulate with the use of a prosthetic limb. Nehler also points out, however, that substance abuse is a common obstacle to successful use of a prosthesis and may contribute to falls and subsequent fractures in such a population.
The possibility that this patient will not only continue to abuse alcohol, but that they may use it as a coping strategy, is a legitimate concern regarding the potential for successful physical and emotional recovery.
A primary goal during the acute rehabilitation stay was to provide the patient with sufficient information and resources to manage emotional distress. Trevelyan et al.  reports that the majority of patients interviewed did not receive "satisfactory" support and information. In that light, education, practice, and the availability of a support system were considered high priorities during the acute stay in an effort to facilitate the return to community roles.
- Nehler MR, Coll JR, Hiatt WR, Regensteiner JG, Schnickel GT, Klenke WA, Strecker PK, Anderson MW, Jones DN, Whitehill TA, Moskowitz S and Krupski WC. Functional Outcome in a Contemporary Series of Major Lower Extremity Amputations. Journal of Vascular Surgery; 38:1, 7-14. 2003.
- Trevelyan EG, Turner WA, Robinson N. Perceptions of Phantom Limb Pain in Lower Limb Amputees and its Effect on Quality of Life: a Qualitative Study. British Journal of Pain. 2015. Accessed online http://bjp.sagepub.com/content/early/2015/06/17/2049463715590 884.full.
- Isenberg, P. Emotional Recovery: the Long and Winding Road. First step: A Guide to Adapting to Limb Loss. 2009: 5:23-24.