Lower Extremity Amputation Problems: Etiology, Manifestations, and Prevention
Gustav Rubin, M.D., FACS, *
Malcolm Dixon, M.A., R.P.T. *
Erich Fischer, C.P. *
It is the purpose of the authors to document, in a concise chart format, a selection of amputation problems encountered by the Clinic Team at our Center, with suggestions for prevention and treatment. Such problems for the amputee may be caused by any of the individuals concerned with his care.
Under ideal circumstances, a surgeon qualified to do amputation surgery will select the most appropriate level for amputation and properly contour the amputation stump; a hospital team will provide efficient rehabilitation; a prosthetist will achieve a satisfactory fit; and the amputee, fully informed about the function of his prosthesis and its components, will ambulate in relative comfort, and will cooperate in a follow-up to allow adjustments to be made for anticipated changes.
Unfortunately, ideal circumstances do not always exist. This paper is presented as a plea to prevent those relatively small, yet significant, number of deviations from less than ideal circumstances. When the amputee has the potential to ambulate, and to ambulate well and relatively comfortably, it is his right to be given the fullest opportunity to realize that potential.
The type of trauma and, in the case of disease states, the character of the neurovascular involvement, will affect the surgeon's decisions. A very effective method for determining the optimum amputation level for the vascularly impaired limb is that of employing xenon133.
Chart 1. , Chart 1.
When the surgeon has been presented with a patient, whose limb has sustained extensive trauma of a degree which mandates amputation, his choices are frequently limited. The status of the traumatized limb may require surgical ingenuity and maximum use of the remaining anatomic structures to contour a residual limb that will provide optimum function. He should not, however, insist on saving all length when such heroic measures will result in a poor residual limb. For an individual of average height, a six inch below-knee residual limb is far more desirable than an amputation eight to 10 inches in length. The feature was discussed many years ago by Thomas and Haddan in their text, "Amputation Prostheses," but is still overlooked. In the case of below-knee amputations, they reported that "amputations below the middle of the leg are to be condemned. The additional bone length offers no advantage in leverage, and the longer stumps are apt to be tender and are prone to vascular difficulties with edema and ulceration of the end of the stump." Saving all length should be an axiom followed with discrimination.
Useful functional length should not be sacrificed. When the amputation is elective, it is the responsibility of the surgeon to make a very careful determination of the level of amputation, particularly, to avoid an above knee amputation if a functioning below knee residual limb can be salvaged. Although it is not possible to cover every eventuality, the chart refers to important problems.
Fig. 1, Fig. 2, Fig. 3, Fig. 4,Fig. 5, Fig. 6, Fig. 7, Fig. 8, Fig. 9, Fig. 10
Chart 2., Chart 2.
Many of the more frequently encountered problems traceable to the prosthetist are listed in the accompanying Chart. The prosthetist has a major responsibility for the optimum rehabilitation of the amputee. Less than total satisfactory fit, alignment, and suspension may cause any variety of problems such as those referred to in the chart. A large selection of prosthetist related problems has been detailed. There will undoubtedly be areas of controversy particularly with reference to the posterior of the socket. At our center we eliminate the popliteal bulge entirely, but at other centers this is frequently retained. When this bulge is exaggerated, as in the illustration, problems may arise.
Fig. 11, Fig. 12, Fig. 13, Fig. 14, Fig. 15, Fig. 16, Fig. 17, Fig. 18
The patient may, himself, be the source of his own difficulties, usually because of carelessness or neglect of instructions. Patients are told to be seen by the clinic team or prosthetist at the first sign of residual limb irritation. Nevertheless, they will often wait and come in after blister formation or even soft tissue breakdown and ulceration have developed.
There are occasions when the residual limb has been so contoured that revision is indicated but the patient refuses further surgery. It is necessary in these cases to warn the patient about the potential for breakdown, so that he may observe certain areas more carefully than he might do otherwise. Examples of this are the excessively long below knee residual limb with poor distal circulation or the inexcusable retention of an excessively long fibula on which the patient refused another operation.
The patient must understand that he is an important member of the clinic team and his subjective responses will be carefully listened to and acted upon when appropriate. Warning signs are: discomfort over bone prominences, redness, swelling, pain, or other manifestations of irritation. These signs should be heeded before breakdown occurs. This may be most likely to occur over the fibular head, tibial crest, or distal anterior tibia of the below-knee amputee, or over the distal lateral aspect of the residual limb of the above knee amputee, if the prosthesis has not been properly fabricated, modified, or fitted.
Fig. 19, Fig. 20, Fig. 21, Fig. 22
THE THERAPIST AND NURSE
Pre- and post-amputation in-hospital care are the responsibility of the therapist and nurse under the guidance and control of the amputating surgeon. Chart. 4 includes some of the more obvious aspects of their responsibilities. In addition, the therapist will also be responsible for teaching the patient many other essentials, such as: how to fall and how to rise from the floor, how to use crutches or a cane when necessary, how to wrap the residual limb, and how to use simple hygienic measures in residual limb care. There is never a reason for one frequently encountered post-amputation problem to occur, such as the flexion contracture that is, unfortunately, seen too often. This should be avoided with proper nursing and therapy care.
Very often, it is a capable, sensitive, and experienced therapist who will take the opportunity to understand and discuss with the patient the psychological impact of his amputation. He will be aided in the process if other actively functioning, rehabilitated amputees are brought in to talk with the amputee and to demonstrate how they have coped with their amputations and have returned to society as active working family members of that society. There is no better way to help the new amputee diminish the psychological impact of the loss of a limb than by other amputees demonstrating that-there will be a future for him.
Fig. 23, Fig. 24
Finally, there are certain specific diseases which affect the status of the residual limb, examples of which are mentioned in Chart V. There are a multiplicity of skin problems which have been presented in detail elsewhere (and which may occur anywhere on the body). These become more serious problems when they present themselves on the residual limb. Various skin lesions may be noted such as psoriasis, herpes zoster, or even tumors. These should be treated by a physician or dermatologist in conjunction with the prosthetist. Whenever consultation with an internist, dermatologist, neurologist, or other specialist is necessary, the clinic team should arrange such consultation.
THE CLINIC TEAM
The Clinic Team has the responsibility for not only prescribing a prosthesis and evaluating the finished limb, but also for follow-up and subsequent care. The prosthesis chosen should provide the amputee with optimum function for the particular stage of rehabilitation. As an example, a temporary above knee prosthesis may be an initial prescription with an adjustable polypropylene socket and a single axis knee, but after sufficient limb maturation has occurred, the active amputee should be allowed to progress to a suction socket and a hydraulic knee if appropriate. Unless there is a financial problem, or an unusual special circumstance such as difficulty of access to a prosthetic facility, a vigorous amputee should not be required to ambulate with a single axis constant friction knee. Chart. 6 illustrates problems which are the responsibility of the clinic team.
The prevention and treatment of amputation problems is a basic goal of everyone concerned with the care of the amputee. Fortunately, such problems are the exception rather than the rule. But when they do occur, these problems may be catastrophic for the amputee, requiring lost time from work, and even, if no other solution is satisfactory, limb revision (Fig. 25 ). This may mean that the patient will have to start the entire process all over again.
- Burgess, E.M., Romano, R.L., and Zettl, J.H., "The Management of Lower Extremity Amputations," U.S. Government Printing Office, Washington, D.C., TRIO-6, August 1969.
- Hoaglund, F.T., Jergesen, H.E., Wilson, L., Lamoreaux, L.W., and Roberts, Ruth, "Evaluation of problems and Needs of Veteran Lower Limb Amputees in the San Francisco Bay Area During the Period 1977-1980," Journal of Rehabilitation R&D, July 1983, 20:1 (BPR 10-38), p.p. 57-71.
- Malone, James M., "Comprehensive Management of Upper and Lower Extremity Amputation," Rehabilitation R&D Progress Reports, 1983 p.p. 3 & 4, Veterans Administration Department of Medicine and Surgery, U.S. Government Printing Office, Washington, D.C.
- Thomas, A., and Haddan, C, Amputation Prosthesis, J.B. Lippincott Company, Philadelphia, London, Montral, 1945, p. 19.
- Levy, S. William, Skin Problems of the Amputee, Warren H. Green, Inc., St. Louis, Missouri, U.S.A., 1983.
- Rubin, G., and Fischer, E., "Selection of Components for Lower Limb Amputation Prostheses," Bull. of the Hosp. for Joint Diseases Orthopedic Institute, Spring, 1982, XL11:1, p.p. 39-67.