HIT and Amputee Care: Amputee Case Study

Title

HIT and Amputee Care

Abstract

This 72 year old gentleman experienced a complication from a lobectomy for lung cancer resulting in a transtibial amputation. He continued to have problems with healing of the incision resulting in an transfemoral amputation. Six weeks status post surgery, he presented to amputee clinic. He had been compliant with the discharge instructions given him by this therapist and he was ready to have his first prosthesis fabricated. He will receive outpatient physical therapy once he has the prosthesis and return to clinic for assessment in 3-4 weeks.

Key Words

HIT, transferal, transtibial, VA/DoD

Client Characteristics

This 72 year old retired farmer lives with his wife in their farmhouse. He was diagnosed with non-small cell carcinoma of the right lung. He underwent a lobectomy with initially good recovery. One week post surgery he experienced significant pain in his right lower leg. He came to the emergency room and was found to have developed HIT (heparin induced thrombocytopenia). He underwent an emergency thrombectomy with immediate redevelopment of the thrombus. Two days later he underwent a transtibial amputation but it did not heal. In the end, 2 weeks later, he required a transfemoral amputation.
The patient had been an active gentleman and generally healthy with his only pre-morbid diagnosis being rheumatoid arthritis for which he had been taking methotrexate. He was taken off this medication due to the HIT.
Following the transtibial amputation, this PT worked with the patient for 10 days while he was hospitalized and he was re-evaluated following the transfemoral amputation.

Examination Findings

His right upper lobectomy was performed for non-small cell carcinoma with good initial recovery until 6 days post surgery when patient developed HIT requiring emergency thrombelectomy surgery which proved unsuccessful. Patient underwent a transtibial amputation and was evaluated by physical therapy on post op day one. The patient reported his primary goal was to return to independent ambulation and his woodworking hobby. His primary complaint was pain at distal residual limb.
The patient demonstrated limited right knee flexion secondary to pain. Transfers required minimal assistance from supine to seated and moderate assistance sitting to standing at front wheeled walker. A FIM (Functional Independence Measure) was performed. The patient scored 64 out of 190.

The International Classification of Function from WHO[1]

  • Health Condition—HIT (cause of amputation)
  • Body Structures and Functions—transtibial to transfemoral amputation, dehiscence of incision with significant pain, patient initially with positive spirit but became withdrawn and depressed, BMI-27, physically limited due to recent lobectomy but motivated
  • Activities and Participation—no limitations from rheumatoid arthritis, unable to stand on one leg without assistance and walker, requires moderate assistance with most BADL/IADL’s, retired, hobby of woodworking, family constructed ramp into home and wood-working shop
  • Contextual Factors—72 yr old male w/rheumatoid arthritis, supportive family, non-smoker.

Clinical Hypothesis

This patient’s main problems are related to the poor healing of the incision. It is extremely painful to the patient, any movement increases pain and limits his ability to perform range of motion and strengthening exercises. The patient was able to mobilize for short periods but the pain limited progress. After the patient underwent the transfemoral amputation the pain was eliminated and healing occurred quickly.

Intervention

The patient was instructed in safe transfers in/out of bed, in/out of wheelchair, and on/off the toilet.3 Following the first amputation, the surgeons did not want any compression to the residual limb. After the revision surgery, the patient was instructed in use of a shrinker sock, desentization exercises and the process of amputee care through the VA Medical Centre. He was provided with a wheelchair, walker, raised toilet seat with arms, shower chair, reacher, long handled sponge, and dressing stick. Home physical therapy was ordered.

Outcome

At the time of discharge following the transfemoral amputation (1 week of hospitalization), the patient was able to transfer independently, all modes, He was independent in wheelchair mobility and was able to ambulate with the walker for >100 feet with standby assistance. The patient was able to verbalize and independently perform his exercise program. He was able to lie prone for 15 minutes. The patient reported minimal pain in the residual limb and healing occurred steadily to the point that six weeks after the amputation his incision was fully healed.
The patient, wife and daughter attended Amputee Clinic 2 weeks ago and was deemed ready for initial fitting. He chose a prosthetic company and an appointment was set for casting. He will return to clinic after the prosthesis is fit properly.

Discussion

This was a very interesting case. The initial cause for the amputation is a rare and potentially devastating side effect of heparin therapy.[2]Having had significant experience with amputee care, this was the first amputation due to HIT with whom I have worked. It reminds me to pay close attention to the report of pain given by a patient, especially if it comes on a period of time after the amputation. And, I would encourage all therapists to be aware of this cause.
Having the VA/DoD book developed for amputees, The Next Step,[3] to provide to the patient is very helpful. It is full of information pertinent to a new amputee. I also feel it is very important to provide the patient’s with written information about what they are to expect as they progress toward their prothesis and new life. This allows the patient and family to refer back to this written information once they have returned home.

[4]

References

  1. World Health Organization (WHO). International Classification of Functioning, Disability and Health (ICF). World Health Organization, 2001. Geneva
  2. Ahmed I, Majeed A, and Powell R. Heparin induced thrombocytopenia: diagnosis and management update. Postgraduate Medical Journal. 2007 Sep; 83(983): 575–582.
  3. Clinical Practice Guideline for Rehabilitation of Lower Limb Amputation/The Next Step. Department of Veterans Affairs/Department of Defense, 2009.
  4. Carroll, K, Edelstein, J E, Prosthetics and Patient Management - A Comprehensive Clinical Approach. SLACK Inc. 2006. page 28-29.