Post-surgical Care The immediate post-surgical management following amputation is the responsibility of the anaesthetist and the surgical team.
Routine care involves correcting metabolic and electrolyte imbalances.
Most patients will have stump pain and phantom sensation and/or phantom pain.9 In the immediate aftermath of surgery, opiates are usually essential.
Following recovery of full consciousness, it is important to monitor the patient’s response to surgery.
High levels of phantom pain are an indication to start on anti-epileptic-type medication such as gabapentin, pregablin, carbamazepine, etc.
This should be supplemented by simple analgesics.
Recalcitrant pain is treated by stage 2 analgesics such as tramadol.
Additionally, amitriptyline may be added at night to provide sedation and pain relief, but doses used may not be sufficient to act as an antidepressant. (Textbooks on pain relief should be consulted for further details.) As soon as the patient’s general health and cognition have stabilised, the physiotherapist should begin a programme of joint mobilisation in order to prevent contractures, maintain fit- ness and reduce stump oedema.
Patients should be instructed on stump elevation and avoidance of injury.
During the time of surgery, the remaining foot is often neglected.
Attention must be paid to caring for the foot and avoiding heel ulcers.
When medically stable, the patient should be transferred to a rehabilitation ward, where the ethos should be to promote function and independence.
The ward should run at a slower pace, with greater access to clinical psychologists and therapists.
Medical staff have a responsibility to ensure that the patient is haematologically and biochemically stable.
Anaemia should be corrected and diabetes well controlled.
Appropriate analgesia should be instituted and can often be given on an ‘as-needed’ basis.
It is unnecessary for the patient to have unreasonable levels of pain; yet at the same time, they should not be over-sedated and, thus, unable to work with the therapist.
Care of the amputation stump wound should be supervised by specialist nurses.
Appropriate dressings should be used.
For the transtibial (below-knee) amputee, a rigid plaster of Paris cast is advocated.
If this is not feasible, an ‘off-the-shelf’ stump shrinker should be used.
The pneumatic post-amputation mobility aid (PPAM aid)10 may be used from day 7 to mobilise the transtibial and transfemoral amputee.
The device is easily applied and gets the patient
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PSYCHOLOGICAL ASSESSMENT 327
standing upright and weight bearing.
If used appropriately, it helps stump shrinkage, reduces pain, initiates aerobic exercise and gives an immense morale boost to the patient through the sheer joy of standing and walking.
About 40% of amputation stumps11 do not heal by primary intention.
Some of these heal by secondary intention often after a prolonged period of time.
In our practice, patients with unhealed stumps are dressed using the hospital dressing protocol and then mobilised on the PPAM aid.
Stump shrinkage and exercise are most beneficial for healing.
Stump shrinkage reduces oedema thereby reducing wound tension.
Reduction in oedema immediately increases the measured tissue partial pressure of oxygen (TcpO2 ).12 In addition, exercise improves peripheral circulation, which boosts the TcpO2 .
Infected stumps require debridement, drainage and sometimes antibiotics.
Occasionally surgical debridement under anaesthetic is required.
Hasty conversion to a higher level of amputation should be avoided, particularly if it results in the loss of the knee joint.
PSYCHOLOGICAL ASSESSMENT Ablating a limb produces an obvious and visible defect which is often painful and distressing.
There is a high incidence of anxiety and depression following amputation, particularly in younger patients who may have lost their limbs through an element of neglect.
The Hospital Anxiety and Depression Scale13 and Beck Inventory14 are standardised scales that are easily administered.
Various psychological treatments are available.
Cognitive behavioural therapy helps patients to realise that feelings interact with thoughts, fears and behaviour and that all of these are under their own control.
Antidepressant medication may be used to supplement this therapy.
The psychologist should observe the relationship between the amputee and the rehabilitation ward staff.
Over-protective ward staff can create a state of helplessness and dependency.
The clinical psychologist should work with the staff to encourage the patient to gain as much functional independence as is safely possible.
The locus of control15 measures the patients’ views of their own sense of control of their environment.
Amputees generally have an external locus of control soon after surgery and feel they are unable to make progress, unless help is provided.
They accept that their future is controlled by other staff, social services, etc.
On the other hand, patients with an internal locus of control have a firm belief that the outcome of their rehabilitation depends on their motivation and actions.
They take charge of their future and work with the team in planning their discharge.
A good rehabilitation team will foster an internal locus of control among its patients.
Some patients are unrealistic in their abilities, their achievements and the outcome following amputation.
This group may display mild dementia, or memory impairment, as assessed by the Mini Mental Score16 and they may require counselling and guidance. (Care should be taken if the patient is on opiates, or other drugs likely to impair cognition.) The rehabilitation team must work with the patients and their family and carers.
The role of family and carers is important in the outcome (generally single people do less well than those with a family).
A sudden change in the person’s function following amputation may compel his/her partner to change from being a friend or sexual partner into adopting the role of nurse.
This role change can cause the partner to react with denial, anxiety, disgust, guilt and depression, and to become obsessed with a need for information and a desire to protect the patient.
Psychologist should be aware of this change and work with the team to provide appropriate support, counselling and information.
Sexual dysfunction is unfortunately
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328 REHABILITATION OF THE AMPUTEE WITH DIABETES
a common consequence of diabetes.
The burden of amputation causes additional psychological difficulties and physical problems.
If requested, referral should be made to a specialist sexual dysfunction team.
The occupational therapist should begin very early the process of teaching the patient to become independent in activities of daily living: sitting balance to allow hand function, in- dependent transfers, dressing, washing, toileting, etc.
The therapist should also be involved in choosing an appropriate wheelchair and cushion.
Amputees have formed support groups (Limbless Association in the United Kingdom, Amputee Coalition in the United States) that play an invaluable role in providing ‘buddy schemes’, information, support and visiting ser- vices, besides collecting money for ongoing research and welfare.
LEVELS OF AMPUTATION This chapter allows only a brief description of management for different levels of amputation. See also the discussion of amputation in Chapter 26.
Toes It is traditional that ‘minor amputations’ are not often referred to the ‘amputee rehabilitation centre’.
Excision of a toe, part of a toe or a ray of the foot alters the biomechanics to a limited extent.
The patient, however, is still burdened by having a neuropathic foot that requires continued vigilance, podiatry and orthotics.
Orthotics should be limited to pressure-relief insoles and surgical shoes and should not attempt to provide material that fills in the space left by the missing digit.
This can expose a foot with neuropathy to the risk of developing pressure ulcers over the neighbouring toes.
Transmetatarsal Amputations Excision of all the toes is usually performed through the necks of the metatarsals.
The surgeon should endeavour to provide a long full-thickness plantar flap with the suture line placed anteri- orly and not adherent to the bone.
Foot amputations through the tarsometatarsal joint (Lisfranc amputation) or the more proximal amputations through the talo-navicular joint (Chopart ampu- tation) require more care.
The dorsiflexors should be reattached in order to avoid development of an equinus contracture.
Partial foot amputations are appropriate for the less active patient where the expectation is of limited mobility over flat terrain.
These amputations are generally associated with lower mortality, but with a higher chance of non-healing.
About 40% of these procedures eventually require more proximal surgery.11 The main functional consequence of partial foot amputation is the shortening of the toe lever.
This results in some loss of postural stability as well as loss of the terminal stance support during gait.
This is observed as increased postural sway, shortening of the stride and loss of forward propelling power.
A prosthetic replacement is not always necessary.
Depending on the functional length that has been lost and the anticipated level of activity, it may be addressed by provision of a combination of shoe filler orthosis and footwear.