Diabetic Transtibial Amputee with Complication of DVT: Amputee Case Study

Title

Diabetic Transtibial Amputee with Complication of DVT: Amputee Case Study

Abstract

Prolonged immobilisation as well as complications commonly associated with diabetes patients increase morbidity and mortality rates as well as length of rehabilitation and independence levels. Diabetes patients should be monitored closely post-amputation to prevent complications such as deep venous thrombosis (DVT), ulcers and damage to the residual as well as contralateral limb during rehabilitation. Patient education regarding signs of possible complications should be emphasized during and after hospitalisation. Closer monitoring and shorter follow-up, are advised for the diabetic patient.

Key Words

transtibial amputation, diabetes 
foot, ulcer, 
geriatric, immobility, DVT

Client Characteristics

Mr. K is 61 years old and suffers from type II diabetes causing peripheral vascular disease. He had a DVT leading to transtibial amputation of the left leg. He was fitted with a prosthesis with a fixed ankle and was walking very short distances using a standard walker. Balance and endurance was poor and transfers difficult. Three months' post-operatively he suffered another DVT of the contralateral limb, causing great concern of possible bilateral amputation and a complete stop of his rehabilitation. However, the right leg recovered following a four-week hospital stay during which a stent was inserted and the DVT cleared up.

The patient uses diabetes, blood pressure medication as well as Warfarin to prevent further DVT's. No rehabilitation was performed during hospitalisation, the patient left the hospital in a weak state using a wheelchair. He was admitted to a step down facility and rehabilitation started from scratch again. Binding of the stump had to be started again since oedema occurred and the prosthesis did not fit the patient anymore.

Mr. K is a pensioner, previously working in an office (sedentary work), and lives with his 40-year-old daughter (housewife) in a small town approx. 200 km from the rehabilitation facility. He owns an automatic car and his house is accessible for a wheel chair. The garden is fairly level and there are three small steps leading up to the front door of the house. Entrance to the back door is level and easily accessible via wheelchair.

Examination Findings

Evaluation following the second period in hospital, in step down facility was as follows:


  • Residual limb left-Stump skin condition is good, but oedema is present and the patient was not wrapping the stump at all. Prosthesis sock is not fitting anymore.
  • Knee flexion is through full ROM, but extension limited to -20 degrees (not fixed).
  • Muscle strength of quadriceps, gluteus medius is Grade II+ on Oxford scale while hamstring is a Gr. III and Gluteus Maximus Gr. II. Hip extension limited to 0 degrees.
  • Contralateral Limb right-OA of the knee causing pain and stiffness, flexion limited to 90 degrees.
  • Muscle strength of quadriceps, gluteus medius is Grade III on Oxford scale while hamstring and Gluteus Maximus is a Gr. II.
  • Foot ulcer present on the calcaneus. Skin condition and circulation is poor in the lower leg and foot. Upper extremities:
  • No pain and ROM of shoulders full. Weak - patient cannot push up his own weight.

  • General: Blood pressure and diabetes under control. Patient takes medication and adheres to correct diet. Needs help for all ADL from nurses.
  • Mobility: Patient uses wheelchair only and needs help for all transfers. He can stand on the right leg using a standard walker with assistance but balance is very poor and he complains of dizziness. Risk for falls are high. Prosthesis socket doesn't fit due to oedema.
  • Psychological: Patient is depressed and fears another limb loss. Says he will never be independent again. He wants to walk with his prosthesis again.

Clinical Hypothesis

Teaching the patient how to care for his contralateral limb as well as the residual limb and to control his diabetes and to know when to seek professional help.
Wrapping stump for oedema control. Foot ulcer care.
General strengthening including upper extremities, residual and contralateral limb while promoting circulation.
Teaching patient transfers from the wheelchair as well as standing independently using walker, in order to gain independence for ADL. Reevaluate walking ability after rehabilitation and seek advise from orthotist/prosthetist regarding prosthesis.

Intervention

I involved the nurse from the diabetes clinic to evaluate and treat the patient's bedsore and give him general info and advice regarding his diabetes, skin care, exercise and diet. She also arranged for him to see a nurse at the clinic in his home town on a bi-monthly basis for help with his diabetes.
Wrapping of the stump was commenced again and the patient taught to do it himself as well and urged to repeat it a few times during the day. Stump massage and tapping was also performed.

General exercises in bed was commenced including all four extremities, addressing ROM, muscle strength and positioning [1][2]. After a week we did transfers from bed to wheelchair, to other chairs and in the bathroom. Also standing independently only using the walker, improving balance and addressing Orthostatic Hypertension [2][3][4]. Walking slowly with the walker without a prosthesis was commenced after two weeks, bearing in mind protection of the contralateral limb[3].

From week 3-6 the prosthetist reevaluated the patient and made some changes to the prosthesis and socket and rehabilitation of standing, balance and walking with the prosthesis was commenced utilising a standard walker- it gives the patient a more stable base and lessens risk of falling as well as the risk of direct injury to the residual limb. The patient was taught to negotiate steps utilising his walker as well as steps to take should he fall[3]. General fitness level were addressed utlising cycling on an exercise bike.

Outcome

Mr. K returned home after spending 6 weeks in the step down facility. An OT assessed his home and made some adjustments including installing hand railings at the door and bathroom.

The nurse from the diabetes clinic visits him bi-monthly and his daughter helps with his care - she attended rehabilitation with the patient during his last week of stay and was taught to assist him with ADL, donning the prosthesis as well as skin care/foot care and transfers/walking.

The patient can walk independently about 200 m using a walker and his prosthesis and can transfer himself successfully although balance remains an issue - his daughter remains close-by to watch and assist if necessary. The TUG test was performed - By using regression analysis Shumway-Cook used 14 seconds as cut-off time[5]. Thus, if a subject took 14 seconds or longer, he is classified as high-risk for falling. Mr. K. took 70 s to perform this test during week 4 and improved to 24 s at discharge, much improved though still at high risk for falling.

The foot ulcer healed and the patient pays attention to skin/foot care.
The patient's psychological condition improved - he is much more positive and enjoys the independence he gained using his prosthesis.

He is happy to be home and goes to weekly meetings at the old age home in his home town where he socializes with other patients. The patient was scheduled for re-evaluation at the rehabilitation unit in four months' time and given access to emergency numbers.

Discussion

Mr. K gained independence in his activities of daily living(ADL) following rehabilitation utilising his prosthesis. His next goal is driving.

Studies showed that a patient is at greatest risk for further same-limb amputation in the 6 months after the initial amputation and risk to the contralateral limb rises steadily. Preventive efforts during this at-risk periods for diabetic patients undergoing first-time amputations must be taken since foot ulcers and lower-extremity amputations are disabling complications of diabetes leading to significant increases in mortality and morbidity, most notably recurrent amputation as well as extended periods of hospitalisation and rehabilitation. The risk of reamputation is greater in diabetics with the rate of major amputation of the contralateral limb is 11.6% at 1 year and 53.3% at 5 years[6]. Therefore emphasis should not only be placed on caring for the stump but prevention of complications and injury to the contralateral limb as well, especially in the diabetic patient.

There is an increased rate of mortality for the geriatric patient with an increased number of post operative complications[7]. Due to the age-associated physiologic changes and prevalence of systemic co-morbidities, geriatric patients are at a higher risk of post operative complications including DVT and ulceration[7]. Decreasing the amount of time immobilised in bed will decrease their risk of immobility related complications and survival rate after amputation[8].

References


  1. Gailey, R.S., and McKenzie, A., Stretching and Strengthening for Lower Extremity Amputees, Monograph, Advanced Rehabilitation Therapy, Inc., 59 pages, 1994.
  2. 2.0 2.1 Gailey, R.S., and McKenzie, A., Balance, Agility, Coordination and Endurance for Lower Extremity Amputees, Monograph, Advanced Rehabilitation Therapy, Inc., 44 pages, 1994.2
  3. 3.0 3.1 3.2 Gailey, R.S. , and McKenzie, A. Advanced Gait Training Program for Lower Extremity Amputees. Monograph, Advanced Rehabilitation Therapy, Inc., 30 pages, 1989
  4. Hypertension. 1992 Jun;19(6 Pt 1):508-19. Orthostatic hypotension in older adults. The Cardiovascular Health Study. CHS Collaborative Research Group. Rutan GH1, Hermanson B, Bild DE, Kittner SJ, LaBaw F, Tell GS. http://www.ncbi.nlm.nih.gov/pubmed/1592445?access_num=1592 445&;link_type=MED;dopt=Abstract
  5. Izumi, Y., Satterfield, K., Lee, S. and Harkless, L., 2006, Risk of Reamputation in Diabetic Patients Stratified by Limb and Level of Amputation: 10-year observation, http://care.diabetesjournals.org/content/29/3/566.long, Diabetes Care, Ma
  6. Shumway-Cook A, Brauer S, Woollacott M. Predicting the probability for falls in community-dwelling older adults using the timed up & go test. Phys Ther. 2000;80(9):896-903.
  7. 7.0 7.1 PREVENTING POSTOPERATIVE COMPLICATIONS IN THE ELDERLY, Frederick E. Sieber, and Sheila Ryan Barnett dhttp://www.ncbi.nlm.nih.gov/pmc/articles/PMC30736 75/
  8. Chapter 29 Common Perioperative Complications in Older Patients. Sandhya A. Lagoo-Deenadayalan, Mark A. Newell, and Walter E. Pofahl