Amputation of the lower limb: postoperative treatment and rehabilitation

Essentials

  • Pain management, prevention of venous thrombosis and reduction of swelling in the stump are the principal goals in the acute phase.
  • Physiotherapy should be introduced as soon as tolerated in order to restore optimal functional capacity and mobility.
  • Plans must be made as regards suitable rehabilitation, equipment and adaptations to the patient’s home.

Treatment immediately after surgery

  • Adequate pain management
  • Prophylaxis against venous thrombosis (drug treatment and physiotherapy)
  • Deep breathing exercises particularly for elderly patients (e.g. using a ”blow bottle” device)
  • The patient must avoid
    • supporting the hip and knee in a flexed position
    • sitting in the same position for a prolonged time and any other positions that contribute towards limb oedema.
  • When in bed the patient should also lie in the lateral and prone positions as far as possible (promotes joint extension).
  • In order to reduce swelling the use of compression bandages or an elasticated stockinette is started as early as possible. A vacuum splint also prevents oedema. It can already be applied in the operating theatre.
  • Stump-shaping bandaging should be started as soon as the stump tolerates mild pressure; less pressure should be applied as the winding of the bandage proceeds proximally.
  • The silicone liner socket acclimatisation period may be started as early as 5–10 days after surgery provided that the stump is healing well and normally. The time the silicone liner socket is used is gradually increased; bandaging is continued alongside.
  • The stump must be protected against trauma; haemorrhage will delay wound healing.
  • A peer support person can give practical help to the amputee in many ways.

Exercises

  • These should be started as soon as possible and carried out several times a day.
  • Exercises to the residual limb 1–2 times a day; joint extension is particularly important
    • Lying in the lateral or prone position the stump is slowly stretched and extended back 10–12 times.
    • Standing up, the stump is stretched back as far as possible 10–12 times.
    • Extension exercises of the knee are performed when standing, sitting and lying down 10–12 times.
  • Other limbs and the trunk must also be exercised.
  • There are also exercises to practise standing up as well as exercises to be done in the standing position.
  • Balance and coordination exercises

Prosthesis fitting

  • The silicone liner acclimatisation period is continued until oedema subsides after which the patient is fitted for a socket to take the prosthesis.
  • The fitting of the prosthesis and its timing are assessed individually. It is possible to obtain a custom-fitted silicone socket as early as 3 weeks after surgery.
  • The prosthesis is taken into use under guidance, and the use is gradually increased.
  • Assistive devices are chosen based on moving ability, in the beginning usually a rollator, thereafter e.g. two forearm crutches, one forearm crutch and a walking stick.
  • A home visit by a physiotherapist and an occupational therapist is often needed in the evaluation of alteration work required at home and of the need of assistive devices.
  • If the fitting of the prosthesis is delayed, standing and gait training may be carried out with the aid of an early walking aid.

Follow-up and pain prophylaxis

  • Adequate analgesia should be provided already before the amputation.
  • Weight management is important.
  • The weight-bearing ability of the stump and the suitability of the prosthesis must be monitored.
  • Compression dressings, supporting stockinettes and silicone sleeves may be used against oedema formation.
  • The patient may be eligible for various rehabilitation programmes that are paid from public funds or by insurance.

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Amputation of the lower limb: postoperative treatment and rehabilitation is a sample topic from the Evidence-Based Medicine Guidelines.

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