Older individual with L BKA: Amputee Case Study

Title

Older individual with L BKA

Abstract

A 74-year-old male admitted with LLE cellulitis will undergo a L BKA while in his hospital stay. He was admitted with a history of lymphedema and cellulitis, and was unsuccessfully managing his lymphedema via a lymphedema clinic. Pt with severe PVD, decreased LLE sensation and strength, and decreased functional mobility. Doppler testing, along with a variety of studies, found that the limb was not salvageable.

Key Words

Below-knee amputation, PVD, limb salvage, transfer training, functional mobility, acute care, amputation

Client Characteristics

The patient about which this case presentation is based is a 74 year old male admitted to the hospital from home with chief complaint of LLE pain, swelling, and redness. Pt is married and retired from a local industrial mill. Pt was admitted under the diagnosis of LLE cellulitis. Pt's comorbidities including hypertension, hypothyroidism, diabetes, obesity, coronary artery disease, hyperlipidemia, PVD, and osteoarthritis. Pt had been treated on an outpatient basis for LE lymphdema through a local lymphedema clinic. Pt will undergo L BKA during his hospital stay.

Examination Findings

S:Pt admitted with uncontrolled LLE lymphedema and cellulitis, resulting in pain, discomfort, redness, and limited mobility. Pt with recent stint in outpatient lymphedema clinic, however due to poor patient compliance and a nonsalvagable limb, pt now admitted for possible L BKA. Pt's goal is to increase mobility and decrease pain.

O:On eval, pt performed supine <> sit mod A, sitting balance SBA, sit <> stand from bed mod A with RW, ambulatory transfer bed <> chair with RW and mod A, and ambulated 15' with RW and mod A. Pt states prior to admission, he was (I) with ambulation, intermittently requiring assistance for ADLs. Pt utilizes RW at baseline, with w/c for community mobility. RLE strength grossly 4+/5, LLE strength grossly 4-/5. Decreased light touch sensation LLE and poor proprioception. Tinetti testing revealed 12/28, indicating pt is a high fall risk. Pt with no significant deficits in AROM or PROM, except L ankle dorsiflexion limited to -5*.

Pt lives with his wife in a 1-story home with a ramp, thus stairs are not a barrier at this time. Pt no longer drives. Wife is available for 24 hour supervision/assistance prn. Pt is a Medicare patient. Pt primarily ambulates household distances, limited in the community by pain and poor endurance.

Clinical Hypothesis

Pt with severe PVD resulting in significant LLE (distal to the knee) cellulitis and lymphedema. Testing has revealed poor viability of veins in LLE, with concomitant decreasing functional mobility and community participation. Pt has become a candidate for a L BKA to prevent further vascular and tissue damage, improve function, and decrease pain.

Intervention

Prior to amputation, PT worked primarily to improve pt's functional status and strength to allow for the best possible recovery following the amputation. Goals written included bed mobility, sit <> stand, transfers, ambulation, LE therex, dynamic balance, and patient education. Interventions included transfer training, gait training, neuromuscular re-education, therex, and education.

Following the pt's L BKA, interventions varied. Initially, pain control and prevention of contractures became the first priority. The patient was seen in an acute care setting, thus initially, treatment focused on bed mobility, sitting balance, and therex. Pt education on preventing knee flexion contractures was crucial.

Pt practiced bed mobility to attain sitting position. In sitting, balance training was performed, including reaching and throwing activities. Once tolerated, sit <> stand and transfer training began with the use of a RW. UE therex was included due to the new increase in demand on the UEs for weight-bearing. As tolerated, ambulation training was progressed to include further distances with decreased assistance required. D/C recommendation was to the acute inpatient rehab facility. Communication was emphasized between PT, OT, nsg staff, d/c planners, wound care RNs, and the MDs.

Outcome

At d/c from the acute care facility to the acute inpatient rehab facility, pt status was as follows:
bed mobility: supine <> sit with min A for trunk elevation, and min cueing for hand placement and sequencing.

Transfers: sit <> stand from bed/chair with RW, min A for balance and safety, and min cueing for pacing.
ambulation: pt ambulated 80' with RW and min A for balance, min cueing for RW management and sequencing

Therex: pt performed 2 sets of 20 repetitions of RLE hip flexion, hip abduction, heel slides, ankle pumps, LAQ, and SAQ. Pt performed 2 sets of 20 repetitions of L hip flexion, extension, abduction, adduction, quad setting, and glut setting. UE therex include press-ups, shoulder flexion, shoulder abduction, elbow flexion, and elbow extension with 5lb weights, 2 sets x 25 repetitions.

Sitting balance: pt tolerated sitting for >15 min without trunk support without UE support with SBA, pt performed dynamic activities in sitting with SBA for 10 minutes.


Standing balance: pt performed a Tinetti with the use of a RW, scoring 15/28, indicating balance cont to be a significant deficit, however cont to improve from admission.

Discussion

As this patient was a member of the older population, special attention needed to be paid to sensation, ROM, strength, balance, safety awareness, and psychosocial aspects. Blood pressure was closely monitored to assess for orthostatic hypotension. Because the patient was older, increasing mobility was crucial to help prevent any secondary complications from a hospital stay, including pneumonia, prolonged ileus, and skin breakdown. In this case, an older male was admitted with PVD and underwent L BKA. Seen in an acute care setting, emphasis was placed on functional transfer training and progressing gait as tolerated. Pt was discharged to an acute inpatient rehab facility, which would allow for further challenging of the patient, with the possibility of prosthetic training.

References

  1. Fletcher DD, Andrews KL, Butters MA, Jacobsen SJ, Rowland CM, Hallett JW Jr. Rehabilitatoin of the geriatric vascular amputee patient: a population-based study. Arch Phys Med Rehabil 2001; 82: 776-9.
  2. The Choice Between Limb Salvage and Amputation: Major Limb Amputation for End-Stage Peripheral Vascular Disease: Level Selection and Alternative Options; Peter T. McCollum, BA, MB, B CH, Michael A Walker, MB, Ch B, MD, M Ch, FRCSI, FRCS Ed. http://www.oandplibrary.org/alp/chap02-03.asp