Right Trans-Tibial Amputation with Right Rotator Cuff Repair: Amputee Case Study

Title

Right Trans-Tibial Amputation with Right Rotator Cuff Repair

Abstract

After an infected ankle surgery occurred, a semi-retired farmer underwent a trans tibial amputation as well as a rotator cuff repair. The patient was seen in by an acute care PT starting post-operative day 1. After successful rehabilitation techniques were integrated for 3 days, the patient was prepared for discharge to the acute rehab unit (ARU) for increased independence with transfers, mobility, and activities of daily living (ADLs).

Key Words

acute, transtibial, BKA, rotator cuff, farmer

Client Characteristics

The patient is a 64 year-old male farmer with a significant history of hypertension, hyperlipidemia and low back pain. He is not a smoker or previously diagnosed with diabetes or PAD, and has never sought out treatment for his back pain. He has several grandchildren whom he spends his days playing with, as well as watching/attending college football and basketball games, and working on his farm. He lives in a ranch-style home with his wife on the farm.

He sustained a fall on his farm (currently ran/managed by his son) and had extensive damage to his Right ankle and had partial tears in his Right infra/supraspinatus. The following week he underwent an ankle replacement surgery with plans to repair his rotator cuff when weight bearing restrictions were lifted.

However within 3 weeks he was readmitted to the hospital with an MRSA infection in the hardware and a trans-tibial amputation about 6 inches below the tibial tubercle was performed and his Right shoulder was repaired as well.

Physical Therapy was given orders to "eval/treat LE strengthening and gait training day 1 post-operative Right BKA with rotator cuff repair precautions" while the patient was becoming medically stable in the hospital.

Examination Findings

As I was able to interview the patient, he told me his shoulder and leg sutures caused him the most pain, which was around 5/10 but managed by pain medications under the direction of the orthopedist and nursing staff. I found that his hypertension was previously managed though medications and diet, and that his main goal was to return to his home and return to previous activities with grandchildren, sports and farm work. He reported that his wife and son were very encouraging and able to support him with ADLs, personal responsibilities and mobility.

He had not yet sat at the edge of the bed and was using a Foley catheter, and looked forward to using a commode and having the catheter removed. In the objective exam, patient's sensation of residual and contralateral limb was intact to light touch and proprioception.

His Right transtibial amputated leg and Right repaired shoulder were not tested for strength per physician request, but MMT of contralateral upper and lower extremities (UE/LE) were WNL. Upon post-op day 1 the patient was willing to perform bed mobility, sit at the edge of the bed, and attempt sit-to-stand transfers. He needed minimal assistance with supine-to-sit transfers, and his vital signs remained stable. He was then guided into a sit-to-stand transfer with a gait belt with maximal assistance and was able to perform Left leg single-leg-stance for over 1 minute with minimal assistance.

Clinical Hypothesis

This patient had debility of mobility and transfers secondary to a trans-tibial amputation with complications of limited Right UE use. Based on my clinical judgment, the physician was awaiting my recommendation for the patient to attend a skilled nursing facility, or to the ARU where he could get up to 3 hours per day for therapy. The hospital's psychologist and social worker were involved too.

I suggested that he be able to attend the ARU, however he still had three days in the hospital with me before this was to happen. The patient needed a lot of education on day one about his journey with rehab these next several weeks and months. Education and training on contracture prevention, as well as other complications that can be prevented with his lungs, anxiety, muscle atrophy, edema, dressings, and more infections were absolutely warranted in order to get the patient on board for proper rehab.

Intervention

On day one, treatment consisted of diaphragmatic breathing for relaxation, Right Hip AROM, Right LE isometric exercises, therapeutic positioning in neutral to prevent contractures (emphasizing no pillows), and finished with knee extension PROM. The patient performed a sit-to-stand transfer using a RUE platform walker with minimal assistance and was instructed to stand with the nursing staff a few times throughout day as tolerated. For his homework, he was to perform Right Hip AROM in coronal, sagittal, and transverse planes with his Right leg 10 times per hour. He was also asked to perform isometric contractions 2-3 times per day with his Right leg, which included quad sets, glut sets, and pillow squeezes for his PRE[1].

On our next visit we reviewed the isometric PRE's and went through his AROM exercises but now in standing with the platform walker and keeping vital signs stable. As the patient was experiencing more residual limb pain, deep breathing and diaphragmatic breathing were reviewed as well and distraction techniques were discussed. He was also introduced to some desensitizing methods like limb tapping and massage[2]. Limb shaping/coning was also discussed since the end goal for this patient was to be able to fit into a prosthesis and ambulate independently at home/work and within the community[3].

Outcome

Due to the nature of the acute care I'm part of, one of my objectives was to ensure that this patient was discharged to the appropriate setting for his maximal benefit while in their short stay in the hospital. The patient was discharged post-operative day 3 to the ARU and my continued care stopped there, but hopefully not my effect. As a result of the treatment I was able to deliver, he was prepared for the next stage in rehab towards the overall goals of social integration and successful ambulation.

Principles of particular emphasis with this patient included contracture prevention, residual limb strengthening, pain management, edema management, and transfer training. Due to the complication of the recent rotator cuff repair, independence was limited in the 3 days I was able to treat him, but he was on a straight path into the right direction. The next stage in his rehab will focus on independent transfers and gait training, for which he was prepared.

Discussion

In working with this patient I've been able to apply evidenced based principles for effective and efficient rehabilitation towards the patient's goals to be able to return to his preferred activities and social integration. Adhering to strength training, transfer training, ROM and a ton of education along with principles of making everything relevant to the whole person and his goals has helped this patient in his acute care experience with his recent amputation. I was fortunate enough to be in the room when the orthopedist came into the room to talk to the patient before being discharged to the ARU, and he mentioned that 3 years ago he wouldn't recommend amputations over the possibility of saving a non-functioning limb. However, now he realizes that patients function very well, and oftentimes better, when a patient has an amputation and is given proper rehab. His clinical experience ties well into the ICF model to look at the whole person, and this has given me an insight that designing rehab with the person's return to social integration and high level of physical function need to guide my decisions when I get to see a patient post-operative day one.

References

  1. Exercise principles are backed by: http://www.physio-pedia.com/Post-fitting_management_of_the_amputee
  2. Desensitizing techniques can found at: http://www.physio-pedia.com/Acute_post-surgical_management_of_the_amputee.
  3. Resources for limb shaping/coning for prosthetic fitting are at: http://www.physio-pedia.com/Pre-fitting_management_of_the_amputee2