2 P H Y S I O T H E R A P Y SEPTEM BER 1 974 FOUR-DAY COURSE ON PROSTHETICS, AMPUTATIONS AND AMPUTEE REHABILITATION J. C. B E E N H A K K E R , B.Sc. (Phy.) Witwatersrand, D.P.E. (Witwatersrand). M any articles have been written in the various physio­ therapy journals on amputations, which shows that this is something that has worried us all at some stage. In the course given by D r. J. Kolbye and M r. E. Linquist from Copenhagen, ideas were expressed and exchanged in the attempt to find the best way to approach this problem as a team. The greatest impression made on me by this course was the possibility of good team work as is practised at the Copenhagen hospital, which can only be to the patient’s benefit. The importance o f the patient in this team was stressed with the other members playing an equal role in the final rehabilitation o f the patient. W ith out intense pre-operative management, good surgery and a welll fitting lim b, the chances o f a patient returning completely to society were slim. The Surgeon, therapists and prosthetist work in close harmony, and it is found that soon, they are able to interpret and anticipate one another’s wishes.. M a n y o f the fields in the treatment of the patient -overlap, and by the inter­ action of the team, the patient’s rehabilitation is achieved smoothly and m uch sooner than w ould have otherwise been possible. The surgeon must decide on the site of amputation, bearing in m ind that the longest functional length is desirable. Ideally, the stump must be endbearing and well shaped to be able to fit snugly in a total contact socket. By functional length is meant the ability to m anipulate a prosthesis in as norm al manner as possible with well balanced muscles surrounding the stump and m obile joints. Because of the need to preserve as m uch of the lim b as possible, great strides are being made in the assess­ ment o f the viability of the skin. Arteriographs do not give accurate measurement of the skin circulation which is im portant in the healing of the stump. A t a special centre in Copenhagen, patients are referred for tests to determine the state of the circulation. One of the tests is done by means of radio-isotopes which give an indication o f the blood flow through the skin at various levels. It has been found by experience that a diastolic B.P. in the skin of less than 30 m m H g will not allow healing o f ulcers, while pressures of 40-50 m m H g w ill ensure good wound healing. Before surgery is performed, intensive pre-operative treatment is given. This is considered to be one of the most im portant physiotherapy periods when the patient is prepared for final rehabilitation. Strengthening and m obilising exercises to the body as a whole are given to prepare the patient for early weightbearing. This can be achieved by individual strengthening programmes using P .N .F. techniques as well as twice-daily ward classes. The affected leg is exercised as well to gain m axim um strength of muscles which w ill be required to m an ipu­ late the prosthesis. This is even more im portant in the vascular patient who has been incapacitated for some time by pain and ulceration. Positioning of the affected leg and m obility exercises are given to prevent de­ formities, while Buerger’s exercises are used to attemm to improve circulation. It is im portant that patient* do these exercises on their own during the day, aiJ continue them long after discharge. A m o d ifie d ’form using active exercises w h ile the lim b is in the dependant position m ay be advocated as it is said to increase the circulation even more. D uring this stage, which is obviously longer in non- traumatic cases, team work is in evidence. The psycho­ logical preparation of the patient is the duty o f bck surgeon and therapist, although a greater load will 8 \ thrown on the therapist who is with the patient f0J longer periods during the day. She will have to assist in preparing the patient for the am putation, allay his fears and help him to look forward to a more normal life in the case of vascular insufficiency, where the patient has been im m obile and in pain. It is also im portant to control infection prior to surgery and any metabolic complications should be treated. This will include medical treatment of diabetes, cardiac failure and similar problems as well as anti­ coagulants, hyberbaric exposure, and correction of N and H b deficiency to improve the vitality of the skin. It is imperative for the social worker to meet the patient as early as possible to see whether any altera­ tions w ill be needed in the home. In Copenhagen, the therapists are responsible fo r visiting the homes to re­ commend widening of doors, replacement o f stairs with ramps and other adaptations to help the more handi­ capped patient achieve independence. These alterations are paid for by the centre with apparently no difficulty! Im m ediate fitting of a prosthesis is favoured for al­ most all the amputations done. It has been found that the rigid plaster cast applied in theatre has the following advantages: 1 . Improves the healing of the wound. 2. Decreases post-surgical oedema. 3. Minimises pain — most patients report very little pain after 24-48 hours. 4. G ains m aturation of the stump at an earlier stage. 5. Allows early m obilisation and the fitting of a per­ manent prosthesis. W ith in 4 weeks o f amputation, the measurements can be made and by 6 weeks the permanent prosthesis w ill be available. W ith the more conventional treatment of securing the dressing w ith a crepe bandage, the bandage will not stay in place for more than a few hours. The tendency to slip can cause strangulation o f the stump with oedema form ation distally resulting in a wait of several months for stump maturation. This method can also lead to pressure being placed o n one point of the stump, especially with the through-knee am putation, as the patient w ill attempt to hold the lim b in a position of comfort. This pressure can lead to ulceration which w ill delay the rehabilitation of the patient. The rigid cast, on the other hand, will distribute the weight more evenly and prevent this complication. R ep ro du ce d by S ab in et G at ew ay u nd er li ce nc e gr an te d by th e P ub lis he r (d at ed 2 01 3. ) The rigid cast consists o f two sterile stum p socks, Hhesive padding and plaster o f paris. The inner sock • nut on carefully and holds the dressing in place, *Sfter strips of padding are in place to relieve pressure bony points, the outer sock is applied around which °.n tic plaster of paris bandages are used as they are sier to apply with even pressure. A t this stage the surge°n moulds the stump and prevents traction on the scar. When the rigid cast is in place, a connecting mechan- . for the shank and foot piece are added before the 15 tient is returned to the ward. Twenty-four hours later the patient is alllowed up in the parallel bars, with only minimum weight being taken on the stump. Patient is w alked twice a day in the bars which can be progressed t elbow crutches after one week in the younger patient. With older patients the progress is slower although most of the amputees w ill be fitted with their permanent prosthesis by six weeks in the absence of any secondary complications. i' / t he early fitting of a prosthesis is obviously a psy­ chological boost to the patient. The young patient w ill be able to return to his work and hobbies sooner than with the conventional method of treatment, while the geriatric patient w ill be more easily motivated. It w ill also give the team the opportunity to assess the patient’s ability to handle a prosthesis, a chance which every patient should be given. Too often we have seen the elderly patient who was co-operative and enthusiastic in the ward, lose the w ill to persevere. H e is sent home at a fairly early stage due to shortage o f beds and must attend weeks of outpatient treatment where he w ill be taught to walk with crutches, which he often finds very difficult. Coning of his stump is usually necessary which need not have been so if a rigid cast had been used. By the time that his stump is suitable for the fitting of a lim b he has often accepted his fate and resigned himself to a life in a wheelchair. Often a pylon with an open socket is first given, m aking it difficult for the patient to m anipulate. Such a pylon, when not well fitting and giving total contact, feels heavy to the patient, and he finds it awkward to use. I f he had been given the opportunity to w alk with m prosthesis in the early stages, he w ould probably .five found this m uch easier. His balance w ould not have been so disturbed, walking w ould have been less of a strain on his arms and remaining leg and he would have been conditioned into accepting the prosthesis as part of himself. SEPTEMBER 1974 The Geriatric Amputee The earlier the team goes into action, the better the chances of final rehabilitation. As the age o f the popu­ lation rises, so will this problem increase, and these geriatric amputees must be given every opportunity to achieve independence. It has been found that in a unilateral above-knee amputation there is a 50% chance that the patient w ill use the prosthesis. As this patient suffers from vascular disease, the chances of his losing the other lim b are high, which makes it imperative to attempt to get him mobile. A bilateral below-knee amputee is very likely to achieve a functional gait while the bilateral above­ knee patient is never likely to w alk unless he is strongly motivated. 3 In the handling o f these elderly amputees, every effort is made to ensure that the patient will be able to continue living at home. This often necessitates alter­ ing the home and the lim b unit w ill arrange for daily outside help if this is deemed desirable. A lthough these patients are given a wheelchair autom atically, it has been found that this does not alter the num ber of patients who m ake use o f their prosthesis. In the early post-operative care the patients are allowed to spend as much tim e in their wheelchairs as they do in prone lying, which reduces the likelihood of flexion contrac­ tures. The type o f prosthesis made for these patients does, however, present some problems. A lthough the same basic principles apply in the m anufacture of the lim b, certain modifications are nearly always necessary. Sus­ pension belts and straps must provide m axim um com ­ fort and simplicity of application is essential. These amputees often find that the total contact or suction socket is too difficult to get into, and an easier method has to be found. As the patient is also weaker, the lim b m ust be as light as possible, and although this will mean the replacement o f the more intricate and heavier components, it w ill allow more use o f the leg. The patient must feel secure in the lim b as there are often associated problems such as joint damage and poor vision which w ill retard rehabilitation. The prosthesis is therefore built with extra safeguards which m ay lead to abnorm al gait patterns. For example, a locked knee is usually necessary which will cause the patient to go u p on his toes to clear the lim b, but this is pre­ ferable to a better gait which is seldom used. Through Knee Amputation This was considered the most useful operation: if the knee joint could not be saved. It has not been used as frequently as its advantages w ould seem to suggest as the fitting of a cosmetically acceptable prosthesis had been a problem fo r m any years. The through-knee am putation provides a long func­ tional stump, with perfect muscle balance and is fully endbearing. It is ideal in children especially when it is remembered that 80% o f growth of the fem ur occurs at the distal epiphysis. It should also be used in vascu­ lar cases where the chances o f loss of the other lim b are high. D uring operation the patella tendon is secured to the remnants of the cruciate ligaments and the scar comes to lie centrally and posterior which will allow full end- bearing. As the stump gives a wide surface for weight bearing, pressure areas are rare while the bulbous end of the stum p allows fo r good suspension of the prosthesis. Fitting o f a prosthesis has been made easier by the newly designed polycentral knee joint which allows for a more norm al gait pattern. The conventional knee mechanism w ill increase the length of the upper seg­ ment o f the lim b and necessitates medial and lateral side stays, thus increasing the width of the prosthesis, and w ill be cosmetically unacceptable to most female patients. The laced leather socket which used to be used has been replaced by a lighter fibre type. A plate can be cut out on the medial side to allow the bulbous end o f the stump easy access, and w ill be less cumbersome. F I S I O T E R A P I E R ep ro du ce d by S ab in et G at ew ay u nd er li ce nc e gr an te d by th e P ub lis he r (d at ed 2 01 3. ) 4 P H Y S I O T H E R A P Y SEP TEM BER 1974 The four bar linkage knee piece allows for the shank to move under the thigh when sitting, giving a more normal thigh length. A t the same time, it allows for greater stability as the point of rotation is higher up the thigh, and together with the piston action of the shank, control o f the knee swing is possible. W ith these new discoveries regarding the operation and fitting of a prosthesis, it is hoped that more through- lcnee amputations will be performed. It w ould seem to be far superior to any above-knee am putation where there is always some muscle imbalance resulting in a more awkward gait. Below Knee Amputation As every effort should be made to preserve the knee, the pre-operative management is very im portant, to prevent later complications which m ay lead to re­ am putation at a higher site. It has often been found that a lim b which appeared beyond help at first, can be improved by pre-operative control of infection, im ­ provement o f circulation etc., allow ing the below-knee surgery instead of higher up. D uring surgery, an osteomyoplasty is done whereby the muscle ends are secured to the tibia via drill holes and sutures. This is also the technique o f choice in above knee amputations. This is done to produce a reasonable shaped stump which is usually healthier and gives greater proprioceptive sensation. The stum p will hold its shape as muscles cannot retract, and if com ­ bined with a rigid cast, oedema is prevented. The earlier myoplasties in which a muscle lo o p was formed, did lead to a floating bone w ithin the stump and the form ation o f a painful bursa, which is now prevented by securing the muscles to the bone. The patella tendon bearing prosthesis is the one of choice although modifications o f this are now being used. The norm al P.T.B. prosthesis gave some instability with very short stumps, and its suspension was one of its weak points. Thus the patella-tendon supra-patella prosthesis is now used which allows for a higher socket and suspension over the condyles. In all below-knee prostheses the socket must be a total contact one with pressure taken on all areas and not only on the patella tendon, otherwise oedema and ulceration may result. Great emphasis was placed on the im mediate or very early fitting o f a prosthesis to allow m axim um rehabilj. tation. This has also been found to be true in the limb deficient child, especially where the upper lim b is in­ volved. In the past, a prosthesis was supplied a t the age of five, but it was found that by this stage, the child had learnt to adapt and usually rejected the arti­ ficial lim b. Hence the baby is now fitted with a simple arm and mitten at the age of six months. The child learns to accept this as part of him self and w ill make use of the more complicated gadgets which are supplied at two years. r A t the first visit to the centre, the parents and trie rest of the rehabilitation team get together to discuss the reason why a prosthesis will be to the baby’s ad­ vantage. By means of slide shows and weekly meetings with other parents with their similarly affected children, their fears can be allayed and new hope can be instilled. The rehabilitation of an amputee can no longer be divided into different stages but m ust be seen as a continuous process involving all members of the team. It starts when the patient is first admitted, with great emphasis being placed on the pre-operative management. The surgery is an extension of the final aim to inde­ pendence and the patient is not sent hom e until every member o f the team is satisfied that he has reached the m axim um of his ability. He is also not discharged un til the team are sure that he will be able to cope at home, and that all members of his fam ily are geared to his achieving final acceptance back into society. R ep ro du ce d by S ab in et G at ew ay u nd er li ce nc e gr an te d by th e P ub lis he r (d at ed 2 01 3. )