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Stages of Care Postoperative Management of the Lower

Extremity Amputation
StagesofCare
Understandingthetimeframeofrecoveryfromlowerlimbamputationisessentialtothe
designandimplementationofanypostoperativemanagementstrategy.Althoughtoday's
healthcaresystemhasplacedanemphasisonspeed,theconsensuscommitteeparticipants
agreedthatplacinganemphasisonshorteningthetimeofhealingandrecoveryfollowing
limblossisnotnecessarilythewisestpath.
Regardlessoftheetiology,thepostoperativerecoveryperiodaftertheamputationofalower
extremitytypicallyis12to18monthsandsimplycannotberushed.1This'recoveryperiod'
includesactivityrecovery,reintegration,prostheticmanagement,andtraining.Some
membersoftheexpertpaneloftheconsensuscommitteefeltthatsettingfastpacedand
oftenunrealisticgoalscanleadtoasenseoffailureinanindividualwhoisactually
progressingnormally.
Thepostoperativeyearlongcontinuumdoesnotseparateeasilyinto"stages".However,an
attempttodefinethestagesofrecoveryhasbeenmadetofacilitatediscussionofhowthe
goalsevolvethroughouttherehabilitativeprocess.
A.PreoperativeStage
Thepreoperativestagetypicallystartswiththeverydifficultdecisionofwhethertoamputate.
Thisstagealsoincludesanassessmentofthevascularstatusanddecisionsonattemptsto
improvecirculation.Thedifficultprocessoflevelselection,preoperativeeducation,emotional
support,physicaltherapyandconditioning,nutritionalsupport,andpainmanagementalsoall
occurinthisstageofcare.
B.AcuteHospitalPostoperativeStage
Theacutehospitalpostoperativestageisthetimeinthehospitalaftertheamputationsurgery.
Thishospitaltimetypicallyrangesfrom5to14days.
C.ImmediatePostacuteHospitalStage
Ingeneral,thisstagebeginswithhospitaldischargeandextends4,6,oreven8weeksafter
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surgery.Thisisthetimeofrecoveryfromsurgery,atimeofwoundhealing,andatimeofearly
rehabilitation.Frequently,endpointsofthisstagearecharacterizedasthepointofwound
healingandthepointofbeingreadyforprostheticfitting.However,itshouldbenotedthat
healingofaresiduallimbisacontinuousprocess,andthelimbdoesnothaveaclearand
decisivepointof"beinghealed."Furthermore,prostheticreadinessisatransitionpointthatis
difficulttostandardizeandmeasure.Muchofthecurrentresearchcomparingdifferent
postoperativemanagementstrategiesattemptstousethesetwoelusiveendpointswith
varyingresults.
D.IntermediateRecoveryStage
Thisisthetimeoftransitionfromapostoperativestrategytothefirstformalprostheticdevice.
Historically,thisdevicewascalledthe"preparatory"prosthesis,butwiththeuseofhigher
technologyearlierintheprocess,itissometimessimplycalledthe"firstprosthesis."Theterm
"preparatory"hastraditionallybeenlinkedtoverybasicprostheticstylesandcomponents.
Theconsensuscommitteeparticipantsfeltthatthehistoricalinterpretationof"preparatory
prosthesis"isnolongeradequate.
Itisduringthisstagethatthemostrapidchangesinlimbvolumeoccur,duetothebeginning
ofambulationandprostheticuse.Theimmediaterecoveryperiodbeginswiththehealingof
thewoundandusuallyextends4to6monthsfromthehealingdate.Althoughdifficultto
define,thisstageendswiththerelativestabilizationoftheresiduallimbsize,asdefinedby
consistencyofprostheticfitforseveralmonths.
E.TransitiontoStableStage
Thisperiodisdefinedasaperiodofrelativelimbstabilizationafterthefourthstagewhen
rapidlimbvolumechangesoccurred.Althoughlimbvolumechangesarenotasdrasticasin
thisstage,thelimbwillcontinuetochangetosomedegree,foraperiodof12to18months
afterinitialhealing.Historically,thisstagewasmarkedasatransitionfromthe"preparatory"
tothedefinitiveprosthesis.Currently,withtheuseofhighertechnologyandmodularsystems
inthepreviousstage(IntermediateRecoveryStage),thistransitionisnolongerdefinedbya
changeintheprosthesis,butratherachangefromarapidlychanginglimbtoaslower
maturationofthelimb.Theprosthesiswillstillrequireoccasionaladjustments,andvisitsto
theprosthetistwillremainrelativelyfrequentuntilafterthefirstyearofprostheticuse.Modular
systemsareappropriateandencouragedtoenhanceeaseofsocketreplacementinthis
stage.
Inthisphasethepatientshouldmovetowardsocialreintegrationandhigherfunctional
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traininganddevelopmentaswellasbecomingmoreempoweredandindependentfromhisor
herhealthpractitioner.
Thefittingofthedefinitiveprosthesismaycertainlyoccurwithinthistimeperiodhowever,
limbstabilizationmustoccurbeforedefinitivefitting.Residuallimbvolumemustbestableso
thedevicecanbeusedforanextendedperiodoftime.Thisextendedperiodoftimeis
typically25yearsinadultsandaslongas1yearingrowingchildren.
Defininglimbstabilityisverydifficult.Formostpatients,theperiodoflimbstabilization
requiresatleast6monthsofprostheticuse.
ClinicalConcerns
Theexpertpanelforthisconsensuscommitteeidentifiedfourteenclinicalconcernsinthe
stagesofrecovery.

1.
2.
3.
4.
5.
6.
7.
8.
9.
10.
11.
12.
13.
14.

DeterminationofAmputationLevel
Minimizesystemiccomplications
Preventcontractures
Bedmobilityandtransfers
Painmanagement
Protectamputatedlimbfromtrauma
Fallprevention
Emotionalcare/education
Manageandteachaboutwoundhealing
Promoteresiduallimbmuscleactivity
Earlyambulation
Advancedambulation
Controllimbvolumechanges
Trunkandbodymotorcontrolandstability

Eachconcernwilltakeonadifferentlevelofimportanceatdifferentstagesofthehealing
process.Sincethegoalsofcarechangeateachstageofrehabilitation,atableofclinical
concernsandtreatmentgoalswasestablishedbytheconsensuscommitteeforeachstage.
(Table1)Theremaybeoverlapbetweenstageswhichmayvarywithindividualdifferences.

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Table1.Changingclinicalconcernsduringthestagesofrecoveryafteralowerlimb
amputation

Theseclinicalconcernsandtreatmentgoalsmaybeusedbycliniciansfordevelopmentof
treatmentprotocolsandguidelineswithintheircommunities.Eachgoalofthetableisranked
inrelativeimportancewithregardtothelevelofclinicalconcernateachstageof
rehabilitation.Forexample,thedeterminationofamputationlevelisofconcernatthe
preoperativestagehowever,itisusuallyoflittleconcernafterthesurgery.Conversely,
emotionalcareisofhighclinicalconcernthroughmostoftherehabilitationprocess,witha
slightdropoffintheintermediaterecoverystageandwitharenewedconcernataround1
yearaftertheamputation.
Althoughprogressionthroughthesephasesislargelyindividual,thetimeneededtoprogress
isreportedconsistentlybetween12and18months.Itisduringthisextendedtimethatmany
individualsstillhavesignificantchangesinlimbvolumethatmustbeconsideredand
managed.Duringthis12to18monthperiod,socialreintegration,lifeplanning,andgoal
settingallprogressaswell.Forpediatricamputees,thestagesofrecoveryandtheclinical
concernsaremodifiedtotakeintoaccountthedevelopmentalmilestonesofthegrowingchild.
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Finally,inthelaterportionsoftheprocesscomethemasteryofprostheticuseandadesired
rangeofactivities.
PhysicalTherapyandProstheticManagement
Althoughtheroleofallteammembersistoassess,educate,andmotivatethepatient,the
roleoftwoparticularmembersoftheteam,thephysicaltherapistandtheprosthetist,during
thislongperiodisoftenunderestimated.
Physicaltherapytreatmentcontinuesthroughoutthisentireperiodwithspecific
rehabilitationprotocolsdesignedtomeetthespecificneedsofeachamputee.Continual
reevaluationandupdatingoftheamputee'sprogramisessentialtoensurethateach
patientreacheshisorhermaximalactivitylevelwithaprosthesis.
Althoughthepatientmustbeanactiveparticipantinhisorherrehabilitativecare,
thetreatmentguidelinesandspecificexercisesarethetherapist'sresponsibility
andanintegralcomponentofthecontinuumofcareforthefirst12to18months.
Initialprostheticmanagementafteramputationrequiresstrategiesdifferentfromthose
usedduringtheperiodafterresiduallimbstabilization.
Duringtheinitialtimeframe,theprosthetistis"chasingamovingtarget,"asthe
residuallimbchangesdramaticallyinvolumeandshape.Therefore,thedefinitive
prosthesisshouldnotbeprescribedorfituntilthelimbhasbeguntostabilizeand
the"movingtarget"hasslowedconsiderably.
Stabilizationisdifficulttodefineandneedstobefurtherresearched.However,
whenapatienthasusedaprosthesisfulltimeforaperiodofatleast6monthsand
whenthelimbvolumehasstabilizedtoapointthatsocketfitremainsrelatively
consistentforatleast2to3weeks,adefinitiveprosthesismaybeindicated.
Intermediateprostheticmanagementconcentratesonedemareductionandtodefine
limbstabilization.
Additionalstudiesneedtobedonetodeterminethemostappropriatetechniqueto
achievethisstabilization.
Littleliteratureisavailablethatattemptstodefinewhenadjustmentofthecurrent
socketmaymeettheneedsofthepatientversuswhensocketreplacementis
required.Clearly,researchisneededinthisarea.
Finally,itshouldbenotedthatapatientmayreturntoworkduringthisrehabilitativeperiod,
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notjustattheendoftheprocess.

CloseWindow[1]

PostoperativeManagementoftheLowerExtremityAmputation
TableofContents[2]

WoundHealing

ImagecourtesyofRobertBrown,CPO,FAAOP

Manylowerlimbamputationsdonothealideallyinaprimaryfashion,anditiscommonthat
smallareasofthewoundrequiresecondaryhealingandaperiodofminoropenwoundcare.
Revisionsurgeryisalsofrequentlyrequired.1
Woundhealingproblemsaremostcommonlyrelatedtotheinjury,disease,vascularity,
tobaccouse,andthenatureofamputationsthemselves.Skinandwoundproblemsarerarely
"caused"byasinglefactorandformanyindividualsarenotpreventable.Itisuncommonfor
lowerlimbamputationstohealprimarilywithnowoundissues.
Itshouldbenotedthathealingofanamputatedlimbisacontinuousprocess,andthereisnot
aclearanddecisivepointof'completedhealing'.Therefore,'timetoheal'isnotaprecise
measure.However,documentinghealingcontinuestobeimportantforpatientcareandfor
research.
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Determininghealingtimeispronetosubjectiveinterpretationofcompletionof:
epithelialization[3],
interpretationofthesmallopenareas,
individualbias,
timingofthereturntoclinicvisits,and
researchsavvyorknowledgeoftheprostheticandrehabilitationteam.
Thisisanareaofsignificantcontroversy.Oftenthedefinitionof"healed"and"healing"varies
fromstudytostudy.Thus,itisimportantthatfuturestudiesclearlydefinehowthe"timeto
heal"hasbeendeterminedforeachparticularstudy.
'Timetoheal'mayalwaysbedifficulttostandardizeandtomeasure,andinrealitycannotbe
determinedaccuratelyfromsimpleretrospectivereviewofaclinicalchart.TheConsensus
Committeedefinedcategoriesofwoundhealingtoaidtheclinicianandtheresearcherin
standardizingthisoftensubjectivearea.Inaddition,theconsensuscommitteemade
recommendationsonwoundhealingandweighbearingactivity.
Thecategoriesare:
A.CategoriesofWoundHealing

CategoryI.

PrimaryHealing:healswithoutopenareas,infection,orwound
complications.(Figures1&2)

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Figure1.CategoryI.Theincisionsiteis
healingwithsomesmallopenareasthat
shouldhealintime.Noinfectionpresent.
ImagecourtesyofJohnRheinstein,CO,
FAAOP&LewSchon,MD.

Figure2.CategoryI.Thesuturesare
removedfromtheincisionsite.Healing
appearstobeproceedingwithsomesmall
openareasthatshouldhealintime.No
infectionpresent.
ImagecourtesyofJohnRheinstein,CP,
FAAOP&LewSchon,MD

Figure3.CategoryII.Ahealingamputationwithfluidandgranulatedtissueinareaswhere
thedrainagetubeswereremoved.
ImagecourtesyofJohnRheinstein,CP,FAAOP&LewSchon,MD

CategoryII.

SecondaryHealing:smallopenareasthatcanbemanagedand
ultimatelyhealwithdressingstrategiesandwoundcare.Additional
surgeryisnotrequired.(Figure3)Thiscanoccasionallybethe
originalplanwithsomeportionoftheamputationintentionallyleft
open.(Figure4)

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Figure4.Openamputation.A,severelyabscessedrightfootofa43yearoldinsulin
dependentdiabeticpriortosupramalleolaramputationandwidedebridementofascending
infectionofallcruralcompartments.B,theanteriorcompartmentwoundat17days
demonstratesgranulationattimeofpartialclosure.C,lateralviewofdistalpartialclosure.
Onlyenoughbonetoeffectmyodesisclosurewasremoved.D,thesameresiduallimb3
monthsfollowinginitialopenamputationthelimbisreadyforprostheticfitting.
Imagecourtesyof:18ATranstibialAmputation:SurgicalProceduresandImmediate
PostsurgicalManagement.In:BowkerJH,MichaelJW,eds.AtlasofLimbProsthetics:
Surgical,Prosthetic,andRehabilitationPrinciples,2ndedition,Rosemont,IL:AAOS,2002.
ImagedownloadedfromtheO&PVirtualLibrary,www.oandplibrary.org[4]AccessedJune
2008.

CategoryIII.

Requiresminorsurgicalrevisionofskinand/orsubcutaneous

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tissuebutnomuscleorbone.(Figure5)

Figure5.CategoryIII.Anexampleofawoundwithareasofnecroticskin.Thislimbwill
requireminorrevisionsurgerytothewoundsiteandmoreaggressivetreatmentprotocolsto
preventamajorrevision.
ImagecourtesyofNUPOC

CategoryIV.

Requiresmajorsurgicalrevisioninvolvingmuscleand/orbone
however,thewoundhealsatinitialamputation'level'.Forexample,a
midlengthtranstibialamputationthatisrevisedandeventuallyheals
atashortertranstibiallevel.(Figure6)

CategoryV.

Requiresrevisiontoahigheramputationlevel.Forexample,a
Symesamputationthatmustberevisedtoeitheraknee
disarticulationoratransfemoralamputation.(Figure7)

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Figure7CategoryIVpossibleCategoryV.Ifinfectionhasreachedtheboneand
oseteomyelitishassetinthenrevisionoftheskin,muscleandbonewillberequiredtoa
moreproximalamputationlevel.
ImagedownloadedfromtheO&PVirtualLibrary,www.oandplibrary.org[5]AccessedJune
2008.

Formoreinformationregardingwoundhealing[6],visitthefollowinglinks:
B.WoundsandWeightBearingActivity

ImagecourtesyofJohnRheinstein,CP,FAAOP&LewSchon,MD

Presenceofanopenwoundorthepresenceofsuturesdoesnotnecessarilyprecludeweight
bearing.Theinstitutionofactivity,orevencontinuationof,canbehelpfulincontrollingedema
andfacilitatinghealing.Thishasbeendemonstratedintheliteraturesincetheearly1920s.2
Althoughinitialinstinctsaretoavoidprostheticuseandweightbearingwheneverthereisa
woundorskinproblem,thismaynotbeappropriateinsomecases.Whileatreatingphysician
mustexaminethewoundandtheprosthetistmustexaminethedeviceforevidenceofdevice
specificpressurepoints,theliteratureactuallysupportsweightbearingandcontinuedactivity
incertainsituationstoenhancewoundhealing.3,4However,moreresearchneedstobe
conductedtoelucidatethemostappropriatedurationandamountofweightbearingto
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enhancewoundhealing.
Gooddirectcommunicationabouthealingissuesandwoundsamongprovidersandeducation
ofthepatientarevital.Repeatedwoundassessmentandmodificationofthetreatmentplan
asneededareimportant.Decisionsregardingweightbearingactivityshouldbemadebased
on:
1. theprogressionoftheparticularwound,
2. thelackofprogression,or
3. theworseningwoundappearance.

CloseWindow[7]

PostoperativeManagementoftheLowerExtremityAmputation
TableofContents[8]

References
1. ^CloseWindow(www.oandp.org)
2. ^TableofContents(www.oandp.org)
3. ^ViewExpandedContent(www.oandp.org)
4. ^www.oandplibrary.org(www.oandplibrary.org)
5. ^www.oandplibrary.org(www.oandplibrary.org)
6. ^ViewExpandedContent(www.oandp.org)
7. ^CloseWindow(www.oandp.org)
8. ^TableofContents(www.oandp.org)
ExcerptedfromStagesofCarePostoperativeManagementoftheLowerExtremityAmputation|AmericanAcademyofOrthotists
&Prosthetists
http://www.oandp.org/olc/lessons/html/SSC_02/07stages.asp?frmCourseSectionId=514F43738EDF434ABA08
C221FA8ABD71

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READABILITYAnArc90LaboratoryExperimenthttp://lab.arc90.com/experiments/readability

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