Post-Operative Assesment and Mangement of a Transtibial Amputation: Amputee Case Study


Original Editor - Abby Cain

Title

Post-Operative Assesment and Mangement of a Transtibial Amputation: Amputee Case Study

Abstract

The assessment and treatment of a 77-year-old male with a recent transtibial amputation, who was already a left below knee prosthetic user. The reason for amputation was vascular compromise leading to a non-healing leg ulcer. The assessment was pre-prosthetic focusing on acute treatment and facilitation of discharge to the home environment from an inpatient setting.

Key Words

Transtibial, Independence, Outcomes measures, Physiotherapy, MDT, Transfers, Goal setting

Client Characteristics

Demographics:

  • 77-year-old male
  • Retired

  • No recent admissions

Present Condition: Non-elective admission for a Right transtibial amputation on 15/6/15 History

Present Condition: Admitted with leg pain and non-healing right leg ulcer. Patient had the ulcer since an MRSA infection for a few months prior to amputation. Non-healing ulcer, due to history of peripheral vascular disease.

Past Medical history: 
Peripheral vascular disease. Hypertension. TIA 2002- leading to carotid endarectomy. COPD, Previously laparoscopic cholecystectomy. Right hemi-arthroplasty Nov 2013 secondary hip fracture. History 2 x MI's more than 3 years ago. Left transtibial amputee 2000- prosthetic limb user.
 Ex-smoker 2 years ago.

Examination Findings

Subjective:

History Patient lives with his wife in a one level access flat. Has a manual wheel chair for inside use and an electric wheelchair for outdoors- due to the flooring on the corridors outside the property making self propel difficult. Patient was a prosthetic user for a transtibial amputation on the left side. Patient was independently mobile over 50-100 yards and was able to manage stairs.
Non driver. No specific hobbies highlighted except reading and watching TV. Patients perceived problem- pain-tender to touch over the underneath aspect of the stump NRS 8/10


Patient's goals and expectations: 


  1. To be independent with transfers in and out of the wheelchair
  2. To be able to perform own activities of daily living including washing/dressing and making cups of tea.
  3. To be independent with toileting

  4. To receive a limb and return to pre-amputation level of mobility
  5. To return to his own living environment on discharge from hospital-did not want to go to in-patient rehab/intermediate care
  6. To be able to manage stairs.

Objective examination:

Body function and Structure Impairments

Upper limb ROM--Full range of movement. No impairment right and left
Muscle power -4+/5 globally in both uppers limbs

Core Stability- Able to sit independently on the edge of the bed and reach outside base of support. Unable to bridge in lying due to prosthesis on left side.

Lower limb-

  • 
Left- Rom-Hip - full movement
. Knee- full extension. 

  • Muscle power - Hip- ext 5/5, flexion 5/5, abduction 5/5, adduction 5/5
 Knee- flexion and extension 5/5
  • 
Sensation Normal
Skin- No Abnormalities. Scar well healed and loose.
 Oedema- No residual swelling
Pain- No residual limb or phantom limb pain

  • Right-ROM- Hip - Flexion 90, abduction 45
Knee- flexion full, ext -20
Muscle powerHip- 4+/5 Knee 4+/5

  • Sensation- Tender over the underneath aspect of the end of stump.

  • Skin- End of the stump mildly pink. Dressing over wound. Mild oozing noted

  • Oedema- oedema collecting under the base of the stump.
  • Pain- residual limb pain under the bas of the stump. Occasional phantom sensation in toes described as 'tingling'

Gait/metabolism expenditure- increased energy requirement sue to use of left below knee prosthesis. With further increased energy requirements due to right transtibial amputation resulting in from a vascular origin.

Gait- unable to mobilises due to recent surgery and timescales of operation in relation to gait rehabilitation commencement. Transfers- Unable to transfer due to previous amputation on the left.

Activities:

  • Mobility- unable to mobilise due to amputation. Patient is independently able to self propel in his wheelchair. He was comfortable with wheelchair use before the operation due to his past medical history.
  • Transfers- Patient unable to transfer independently due to the recent operation of transtibial right amputation.
  • 
Toileting- unable to use toilet independently- toilet frame surrounding toilet at home therefore needed to be able to pivot transfer on/off the toilet.
  • Washing- patient is able to wash himself independently on the wash from a seated position. The patient needed assistance using the shower on the ward.

  • Dressing- patient able to independently wash and dress himself on the ward
  • Preparation of meals- patient lived with his wife who normally prepared his meals. Patient was previously able to make a cup of tea from his wheelchair position. This would be unaffected however patient was prior to admission able to make a cup of tea from a standing position also.
  • 
Transport- patient was previously able to independently use public transport using his wheelchair.

Participation:

Patient is normally able to do his own shopping in town using public transport. No other recreational or leisure activities aware identified. Patient does attend the amputee support group on a monthly basis and transport, normally an ambulance or taxi is arranged for the patient through the charity supporting the class.

Environmental and Personal contextual factors:

The patient's home environment was largely set up for wheelchair use following his previous amputation. He uses an electric wheelchair to travel along the corridor, due to the carpets, which were wide enough for wheelchair use and the flat was situated on the ground floor. The flat was all on one level with no internal steps. There was enough room in the kitchen for wheelchair use and the patient had a perching stool already in place. The patents own environment is a facilitator for discharge as adaptations were already in situ form his previous operation.

Previous personal experience of an amputation was a facilitator in this case as the patient was aware of what to expect and had an understanding of the how he would be limited in terms of activities and participation. However his previous amputation would also lead to difficulties, as higher energy expenditure would be required for tasks and the patient was more debilitated than previous.

The patient did have a Scandia toilet frame around his toilet, which meant he would need to be able to pivot transfer on and the toilet at home, or use alternative equipment. The patient was previously able to transfer though pivot on his unaffected leg. The frame was also identified as a tipping risk. This was a barrier to discharge.


Clinical Hypothesis

Main problems

  • Residual limb pain in the right due to post operation swelling.
  • Struggling to transfer due to previous prosthetic use on left side making pivot transfer more difficult to achieve. Needs to able to transfer independently for home.
  • Previous hip weakness in the right hip following a hemiarthroplasty from a previous neck of femur fracture. May cause potential difficulties in prosthetic use on the right especially in view of the fact patient is now a bilateral amputee.

  • Reduced Rom of in the right knee due to shortening of the hamstrings as a direct result of the reduced lever length and also due to patient being reluctant to try and straighten the knee due to tenderness underneath the stump. This again could lead to potential limitations with prosthetic use if not corrected at the early stage.
  • Patient was already an increased risk of falls which has been increased further by the new amputation.

  • Patient will have higher energy expenditure to use a prosthesis on the right which is further challenged by the current use of prosthetics on the left. However patient did have a previous high level of independence with the prosthetic use and has good potential to progress to prosthetic rehabilitation if the other problems are managed first.

  • Patient's goals and expectations may be slightly ambition to be fully independently mobile; however mobility with an aid is likely to be possible.

Intervention

  • Patient provided with an amputee leaflet which details post op care, roles of the MDT, exercises, what to expect from a rehabilitation point of view, roles of the MDT and general advise.
  • Involvement of the MDT and joint goal setting to plan discharge home from hospital within 10 days of the operation as per the internal amputee 10 day pathway.
  • Referral to Occupational therapy to provide glide about commode to assist in toileting at home.

  • Vascular nurse for provision of juzo sock to help with swelling and stump shaping.
  • Nurses and consultant reviews to aid wound management and medical post op care.


Physiotherapy-


  • Individual exercise programme for hip, knee and upper limbs.
  • Transfer practice- pivot and banana board use Education- on stump massage, scar mobilisation, de-sensitisation and how to reduce phantom sensation.

  • Discussed with patient realistic expectations in relation to prosthetic rehabilitation, incorporating energy expenditure and personalised goals. Falls assessment prior to discharge.

  • Referral to the specialised ability centre for assessments for a prosthetic limb and a referral to the satellite amputee class to commence pre prosthetic rehabilitation.

Outcome

  • Patient was provided with a glide about commode for home to be wheeled over the toilet to help aid transfers.

  • Patient was able to transfer independently through a pivot transfer to the left on his prosthetic side to the wheelchair. However struggled with transfers to the right and therefore was able to achieve independence by removing the wheelchair arm and performing a low pivot to the right.
  • Patient was independent with hip exercises and gained full extension in the right knee proper to discharge.

  • The patient's pain felt confident in managing phantom sensations.
  • Patient began pre-prosthetic training with the PPAM and was accepted for prosthetic limb. His care is still ongoing and has not received the limb to begin rehabilitation with it.

  • The patient was unable to get on and off the floor to practice in case of falls due to his prosthetic use. Risks were managed through pendant alarm and having 24 hour access to help in the accommodation he lived in. Falls advice in relation to long lie were taught and how to review for injuries. Falls prevention advice given provided before discharge home. Plan for further falls assessment in the amputee class once a second prosthesis was provided
•The scar healed well and swelling reduced resulting in a stump shape that allowed for prosthetic use.

Discussion

The patient on initial assessment the patient did have some areas of reduced ROM and muscle strength from a previous injury but also as a direct result from the operation and due to the natural ageing process of the musculoskeletal tissue. However early intervention and exercise were successful in improving this resulting in the approval for a prosthesis. According to the literature an interdisciplinary approach is most effective. In this case it was in supporting the amputee through to discharge by looking at the patient holistically and setting agreed goals, especially in relation to equipment for independence and the stump management to allow onward pre prosthetic rehabilitation.

The MDT worked together with the patient and communicated regularly about the patient's goals in order to meet the amputee 10 day inpatient stay pathway and every one worked towards the same management plan. It has been said that amputees can grieve for the loss of their limb, through 5 stages. Initially the patient appeared display some elements of the bargaining phase during the initial post op days after the surgery as the patient stated various reasons/bargaining positions as to why he couldn't engage with physiotherapy straight away. However the patient progressed through these stages very quickly to acceptance over a course of 3 days. The use of outcome measure helps goal setting and monitors progression.

During the in patient stay these, mainly focused on pain and ROM. There are little outcome measures that are suitable for the in-patient stay pre-prosthetically as the measure are mainly focused on prosthetic use. However planned outcome measures to be used for prosthetic rehabilitation are the Houghton score and the loco motor index

References

  1. Barbara Engstrom, Catherine Van de Ven MCSP Therapy for Amputees, 3e Hardcover - 17 May 1999
•World Health Organisation (WHO). International classification of functioning disability and health (ICF). World Health Organisation 2001. Geneva.
  2. Lusardi MM, Postoperative and preprosthetic care. In Lusardi, MM, Jorge, M and Nielsen, CC editors. Orthotics and Prosthetics in Rehabilitation, Third Edition. Missouri: Elsevier, 2013.p. 532-594.
  3. Fletcher DD, Andrews KL, Butters MA, Jacobsen SJ, Rowland CM, Hallett JW Jr. Rehabilitation of the geriatric vascular amputee patient: a population-based study. Arch Phys Med Rehabil 2001;82:776-9.
  4. BACPAR toolbox of outcome measure. Version1 2012 BACPAR