Amputee Rehabilitation

Amputation: Levels & Aims - Cutting Edge Care

• Indications: Severe trauma, PVD (e.g., diabetes), uncontrolled infection, malignancy, congenital defects.
• Levels (Lower Limb):
  • Syme's: Ankle disarticulation, end-bearing.
  • Transtibial (BKA): Ideal 12.5-17.5 cm below knee joint.
  • Transfemoral (AKA): Ideal 25-30 cm below greater trochanter.
• Levels (Upper Limb): Transradial, Transhumeral.
• Surgical Aims for Ideal Stump:
  • Optimal length & shape (conical/cylindrical).
  • Painless, mobile scar (posterior in BKA).
  • Muscle stabilization: myodesis/myoplasty.
  • Good padding & vascularity.

⭐ Transtibial amputation: Posterior myocutaneous flap is preferred for better stump vascularity and padding.

Stump: Care & Complications - Healing the Hub

• Post-Op Stump Care:

  • Edema Control: Crucial for healing & prosthetic fit.
    • Methods: Rigid (RRD), semi-rigid, soft dressings (elastic figure-of-eight bandaging).
  • Pain Management:
    • Stump pain (local) vs. Phantom limb pain (neuropathic).
  • Hygiene: Daily cleaning, inspection.
  • Positioning: Prevent contractures (e.g., avoid prolonged hip/knee flexion).

• Stump Maturation:

  • Desensitization: Tapping, massage.
  • Shaping: Conical/cylindrical for prosthesis.

• Common Complications:

  • Early: Infection, hematoma, wound dehiscence, skin necrosis, DVT.
  • Delayed/Late:
    • Contractures (hip flexion, knee flexion most common).
    • Neuroma (painful nerve ending).
    • Bony spurs, skin breakdown.
    • Phantom limb pain/sensation.

  ⭐ Phantom limb pain occurs in 50-80% of amputees; often managed with mirror therapy, gabapentinoids, or TCAs.

• Prevention Focus:

  • Early mobilization, proper bandaging, meticulous surgical closure.

Prosthetics: Types & Tech - Bionic Blueprints

• Types:
  • Temporary: Early training, stump shaping.
  • Definitive: Long-term, customized.
  • Exoskeletal: Hard outer shell, durable.
  • Endoskeletal: Internal pylon, lighter, adaptable, cosmetic.
• Key Components:
  • Socket: Stump interface. Transtibial: PTB, TSB. Transfemoral: Ischial Containment, Quadrilateral.

    ⭐ Ischial containment sockets provide better medio-lateral stability for transfemoral amputees compared to quadrilateral sockets.

  • Suspension: Holds prosthesis. E.g., Suction, Pin/Lanyard, Silesian belt.
  • Shank (Pylon): Connects socket to foot/knee.
  • Knee Units (Transfemoral): Single-axis (fixed cadence), Polycentric (variable cadence, ↑stability), MPK.
  • Ankle-Foot Assemblies: SACH (basic), Dynamic Response (energy storing).
• Checkout: Static (comfort, length), Dynamic (gait, stability).

Rehabilitation: Phases & Gait - Stepping Forward

• Goal: Maximize functional independence, QoL.
• Pre-Prosthetic Phase: Stump maturation (edema control, shaping, desensitization). ROM, strengthening (esp. extensors, abductors). Phantom pain management.
• Prosthetic Training Phase: Prosthesis: Don/doff, care. Balance (static, dynamic).
  • LL Gait Training: Progression (parallel bars→aids→unaided). Aim: smooth, symmetric, energy-efficient.
    • Common Deviations:
      • Circumduction (long prosthesis, weak hip flexors).
      • Vaulting (long prosthesis, ↓knee flexion, fear).
      • Lateral Bend (weak abductors, short prosthesis, pain).
      • Trendelenburg (gluteus medius weakness).
  • UL Functional Training: Terminal device control, grasp patterns, ADLs.
• Key: Continuous psychological & vocational support. 📌 S.T.E.P. Forward (Stump, Training, Exercise, Psych).

⭐ Vaulting (rising on sound limb) during prosthetic gait often indicates the prosthesis is too long, there's insufficient prosthetic knee flexion, or fear of weight-bearing.

High‑Yield Points - ⚡ Biggest Takeaways

• Phantom limb pain is common; manage with mirror therapy, TENS, and pharmacotherapy.
• Crucial stump care involves hygiene, conical shaping, and desensitization to prevent issues.
• Early prosthetic fitting, ideally within 30 days, significantly improves functional outcomes.
• Energy expenditure markedly ↑ with lower limb amputations, especially transfemoral.
• Prevent contractures (e.g., hip flexion in AKA) with proper positioning and regular exercises.
• Gait training is fundamental for achieving functional mobility and independence with a prosthesis.
• Comprehensive psychological support is integral throughout the entire rehabilitation process for adjustment.