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Stages of Care - Postoperative Management of the Lower
Extremity Amputation
Stages of Care
Understanding the time frame of recovery from lower limb amputation is essential to the
design and implementation of any postoperative management strategy. Although today's
health care system has placed an emphasis on speed, the consensus committee participant
agreed that placing an emphasis on shortening the time of healing and recovery following
limb loss is not necessarily the wisest path.
Regardless of the etiology, the postoperative recovery period after the amputation of a lower
extremity typically is 12 to 18 months and simply cannot be rushed.1This 'recovery period'
includes activity recovery, reintegration, prosthetic management, and training. Some
members of the expert panel of the consensus committee felt that setting fast-paced and
often unrealistic goals can lead to a sense of failure in an individual who is actually
progressing normally.
The postoperative year-long continuum does not separate easily into "stages". However, an
attempt to define the stages of recovery has been made to facilitate discussion of how the
goals evolve throughout the rehabilitative process.
A. Preoperative Stage
The preoperative stage typically starts with the very difficult decision of whether to amputate
This stage also includes an assessment of the vascular status and decisions on attempts to
improve circulation. The difficult process of level selection, preoperative education, emotiona
support, physical therapy and conditioning, nutritional support, and pain management also a
occur in this stage of care.
B.Acute Hospital Postoperative Stage
The acute hospital postoperative stage is the time in the hospital after the amputation surgery
This hospital time typically ranges from 5 to 14 days.
C.Immediate Postacute Hospital Stage
In general, this stage begins with hospital discharge and extends 4, 6, or even 8 weeks after
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surgery. This is the time of recovery from surgery, a time of wound healing, and a time of ear
rehabilitation. Frequently, end points of this stage are characterized as the point of wound
healing and the point of being ready for prosthetic fitting. However, it should be noted that
healing of a residual limb is a continuous process, and the limb does not have a clear and
decisive point of "being healed." Furthermore, prosthetic readiness is a transition point that is
difficult to standardize and measure. Much of the current research comparing different
postoperative management strategies attempts to use these two elusive end points with
varying results.
D. Intermediate Recovery Stage
This is the time of transition from a postoperative strategy to the first formal prosthetic device
Historically, this device was called the "preparatory" prosthesis, but with the use of higher
technology earlier in the process, it is sometimes simply called the "first prosthesis." The term
"preparatory" has traditionally been linked to very basic prosthetic styles and components.The consensus committee participants felt that the historical interpretation of "preparatory
prosthesis" is no longer adequate.
It is during this stage that the most rapid changes in limb volume occur, due to the beginning
of ambulation and prosthetic use. The immediate recovery period begins with the healing of
the wound and usually extends 4 to 6 months from the healing date. Although difficult to
define, this stage ends with the relative stabilization of the residual limb size, as defined by
consistency of prosthetic fit for several months.
E.Transition to Stable Stage
This period is defined as a period of relative limb stabilization after the fourth stage when
rapid limb volume changes occurred. Although limb volume changes are not as drastic as in
this stage, the limb will continue to change to some degree, for a period of 12 to 18 months
after initial healing. Historically, this stage was marked as a transition from the "preparatory"
to the definitive prosthesis. Currently, with the use of higher technology and modular systems
in the previous stage (Intermediate Recovery Stage), this transition is no longer defined by a
change in the prosthesis, but rather a change from a rapidly changing limb to a slower
maturation of the limb. The prosthesis will still require occasional adjustments, and visits to
the prosthetist will remain relatively frequent until after the first year of prosthetic use. Modula
systems are appropriate and encouraged to enhance ease of socket replacement in this
stage.
In this phase the patient should move toward social reintegration and higher functional
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training and development as well as becoming more empowered and independent from his o
her health practitioner.
The fitting of the definitive prosthesis may certainly occur within this time period however,
limb stabilization must occur before definitive fitting. Residual limb volume must be stable so
the device can be used for an extended period of time. This extended period of time is
typically 2-5 years in adults and as long as 1 year in growing children.
Defining limb stability is very difficult. For most patients, the period of limb stabilization
requires at least 6 months of prosthetic use.
Clinical Concerns
The expert panel for this consensus committee identified fourteen clinical concerns in the
stages of recovery.
1. Determination of Amputation Level
2. Minimize systemic complications
3. Prevent contractures
4. Bed mobility and transfers
5. Pain management
6. Protect amputated limb from trauma
7. Fall prevention
8. Emotional care/education
9. Manage and teach about wound healing
10. Promote residual limb muscle activity
11. Early ambulation
12. Advanced ambulation
13. Control limb volume changes
14. Trunk and body motor control and stability
Each concern will take on a different level of importance at different stages of the healing
process. Since the goals of care change at each stage of rehabilitation, a table of clinical
concerns and treatment goals was established by the consensus committee for each stage.
(Table 1)There may be overlap between stages which may vary with individual differences.
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Table 1. Changing clinical concerns during the stages of recovery after a lower limb
amputation
These clinical concerns and treatment goals may be used by clinicians for development of
treatment protocols and guidelines within their communities. Each goal of the table is ranked
in relative importance with regard to the level of clinical concern at each stage of
rehabilitation. For example, the determination of amputation level is of concern at the
preoperative stage however, it is usually of little concern after the surgery. Conversely,
emotional care is of high clinical concern through most of the rehabilitation process, with a
slight drop off in the intermediate recovery stage and with a renewed concern at around 1
year after the amputation.
Although progression through these phases is largely individual, the time needed to progress
is reported consistently between 12 and 18 months. It is during this extended time that many
individuals still have significant changes in limb volume that must be considered and
managed. During this 12 to 18 month period, social reintegration, life planning, and goal
setting all progress as well. For pediatric amputees, the stages of recovery and the clinical
concerns are modified to take into account the developmental milestones of the growing chil
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Finally, in the later portions of the process come the mastery of prosthetic use and a desired
range of activities.
Physical Therapy and Prosthetic Management
Although the role of all team members is to assess, educate, and motivate the patient, the
role of two particular members of the team, the physical therapist and the prosthetist, during
this long period is often underestimated.
Physical therapytreatment continues throughout this entire period with specific
rehabilitation protocols designed to meet the specific needs of each amputee. Continua
reevaluation and updating of the amputee's program is essential to ensure that each
patient reaches his or her maximal activity level with a prosthesis.
Although the patient must be an active participant in his or her rehabilitative care,
the treatment guidelines and specific exercises are the therapist's responsibility
and an integral component of the continuum of care for the first 12 to 18 months.
Initialprosthetic managementafter amputation requires strategies different from thos
used during the period after residual limb stabilization.
During the initial time frame, the prosthetist is "chasing a moving target," as the
residual limb changes dramatically in volume and shape. - Therefore, the definitive
prosthesis should not be prescribed or fit until the limb has begun to stabilize andthe "moving target" has slowed considerably.
Stabilization is difficult to define and needs to be further researched. However,
when a patient has used a prosthesis full time for a period of at least 6 months an
when the limb volume has stabilized to a point that socket fit remains relatively
consistent for at least 2 to 3 weeks, a definitive prosthesis may be indicated.
Intermediate prosthetic managementconcentrates on edema reduction and to define
limb stabilization.
Additional studies need to be done to determine the most appropriate technique to
achieve this stabilization.
Little literature is available that attempts to define when adjustment of the current
socket may meet the needs of the patient versus when socket replacement is
required. Clearly, research is needed in this area.
Finally, it should be noted that a patient may return to work duringthis rehabilitative period,
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not just at the end of the process.
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Postoperative Management of the Lower Extremity Amputation
Table of Contents[2]
Wound Healing
Image courtesy of Robert Brown, CPO, FAAOP
Many lower limb amputations do not heal ideally in a primary fashion, and it is common that
small areas of the wound require secondary healing and a period of minor open wound care.
Revision surgery is also frequently required. 1
Wound healing problems are most commonly related to the injury, disease, vascularity,
tobacco use, and the nature of amputations themselves. Skin and wound problems are rarely
"caused" by a single factor and for many individuals are not preventable. It is uncommon for
lower limb amputations to heal primarily with no wound issues.
It should be noted that healing of an amputated limb is a continuous process, and there is no
a clear and decisive point of 'completed healing'. Therefore, 'time to heal' is nota precise
measure. However, documenting healing continues to be important for patient care and for
research.
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Determining healing time is prone to subjective interpretation of completion of:
epithelialization[3],
interpretation of the small open areas,
individual bias,
timing of the return to clinic visits, and
research savvy or knowledge of the prosthetic and rehabilitation team.
This is an area of significant controversy. Often the definition of "healed" and "healing" varies
from study to study. Thus, it is important that future studies clearly define how the "time to
heal" has been determined for each particular study.
'Time to heal' may always be difficult to standardize and to measure, and in reality cannotbe
determined accurately from simple retrospective review of a clinical chart. The Consensus
Committee defined categories of wound healing to aid the clinician and the researcher in
standardizing this often subjective area. In addition, the consensus committee made
recommendations on wound healing and weigh bearing activity.
The categories are:
A. Categories of Wound Healing
Category I. Primary Healing: heals without open areas, infection, or wound
complications. (Figures 1 & 2)
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Figure 1. Category I. The incision site is
healing with some small open areas that
should heal in time. No infection present.
Image courtesy of John Rheinstein, CO,
FAAOP & Lew Schon, MD.
Figure 2.Category I. The sutures are
removed from the incision site. Healing
appears to be proceeding with some small
open areas that should heal in time. No
infection present.
Image courtesy of John Rheinstein, CP,
FAAOP & Lew Schon, MD
Figure 3. Category II. A healing amputation with fluid and granulated tissue in areas where
the drainage tubes were removed.
Image courtesy of John Rheinstein, CP, FAAOP & Lew Schon, MD
Category II. Secondary Healing: small open areas that can be managed and
ultimately heal with dressing strategies and wound care. Additional
surgery is not required. (Figure 3) This can occasionally be the
original plan with some portion of the amputation intentionally left
open. (Figure 4)
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Figure 4. Open amputation. A, severely abscessed right foot of a 43-year-old insulin
dependent diabetic prior to supramalleolar amputation and wide debridement of ascendinginfection of all crural compartments. B, the anterior compartment wound at 17 days
demonstrates granulation at time of partial closure. C, lateral view of distal partial closure.
Only enough bone to effect myodesis closure was removed. D, the same residual limb 3
months following initial open amputation the limb is ready for prosthetic fitting.
Image courtesy of: 18-A Transtibial Amputation: Surgical Procedures and Immediate
Postsurgical Management. In: Bowker JH, Michael JW, eds.Atlas of Limb Prosthetics:
Surgical, Prosthetic, and Rehabilitation Principles, 2nd edition, Rosemont, IL:AAOS, 2002.Image downloaded from the O & P Virtual Library, www.oandplibrary.org[4] Accessed June
2008.
Category III. Requires minor surgical revision of skinand/or subcutaneous
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tissue but no muscle or bone. (Figure 5)
Figure 5.Category III. An example of a wound with areas of necrotic skin. This limb will
require minor revision surgery to the wound site and more aggressive treatment protocols toprevent a major revision.
Image courtesy of NUPOC
Category IV. Requires major surgical revisioninvolving muscle and/or bone
however, the wound heals at initial amputation 'level'. For example, a
mid- length transtibial amputation that is revised and eventually heals
at a shorter transtibial level. (Figure 6)
Category V. Requires revision to a higher amputation level. For example, a
Symes amputation that must be revised to either a knee
disarticulation or a transfemoral amputation. (Figure 7)
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Figure 7Category IV possible Category V. If infection has reached the bone and
oseteomyelitis has set in then revision of the skin, muscle and bone will be required to a
more proximal amputation level.
Image downloaded from the O & P Virtual Library, www.oandplibrary.org[5] Accessed June
2008.
For more information regarding wound healing[6], visit the following links:
B. Wounds and Weight Bearing Activity
Image courtesy of John Rheinstein, CP, FAAOP & Lew Schon, MD
Presence of an open wound or the presence of sutures does not necessarily preclude weigh
bearing. The institution of activity, or even continuation of, can be helpful in controlling edema
and facilitating healing. This has been demonstrated in the literature since the early 1920s. 2
Although initial instincts are to avoid prosthetic use and weight bearing whenever there is a
wound or skin problem, this may not be appropriate in some cases. While a treating physicia
must examine the wound and the prosthetist must examine the device for evidence of device
specific pressure points, the literature actually supports weight bearing and continued activity
in certain situations to enhance wound healing. 3,4However, more research needs to be
conducted to elucidate the most appropriate duration and amount of weight bearing to
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enhance wound healing.
Good direct communication about healing issues and wounds among providers and educatio
of the patient are vital. Repeated wound assessment and modification of the treatment plan
as needed are important. Decisions regarding weight-bearing activity should be made based
on:
1. the progression of the particular wound,
2. the lack of progression, or
3. the worsening wound appearance.
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References
1. ^Close Window (www.oandp.org)
2. ^Table of Contents (www.oandp.org)
3. ^View Expanded Content (www.oandp.org)
4. ^www.oandplibrary.org (www.oandplibrary.org)
5. ^www.oandplibrary.org (www.oandplibrary.org)
6. ^View Expanded Content (www.oandp.org)
7. ^Close Window (www.oandp.org)
8. ^Table of Contents (www.oandp.org)
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