Early Management of Elderly Dysvascular Transtibial Amputees
Toni M. Cutson, MD, MHS
Dennis Bongiorni, PT
>John W. Michael, MLd, CPO
>Gary Kochersberger, MD
ABSTRACT
The majority of transtibial (below-knee) amputations occur in elderly patients with systemic vascular disease.
Rehabilitation efforts toward prosthetic
ambulation are frequently delayed
awaiting postoperative healing of the
vascular compromised limb. Rehabilitation becomes more difficult, more
costly and less successful the longer it is
delayed after surgery, especially among
elderly amputees. Early ambulation reduces the risk of complications such as
thromboembolism, pneumonia and deconditioning in the older patient as well
as enhances remaining life. An early coordinated post-amputation rehabilitation program reduces the time to prosthetic ambulation and the risk of further
debility and failure among elderly amputees. The rigid removable dressing
was incorporated into the program and
found to be a safe method of residual
limb shrinkage among elderly dysvascular transtibial amputees.
Introduction
It is estimated that more than 40,000
lower-extremity amputations are performed annually in the United States
(1). Most of these amputations occur in
elderly people secondary to vascular
disease associated with diabetes or atherosclerosis. Systemic vascular disease
is also a major cause of mortality and
morbidity. Five-year survival rates following amputation of a lower extremity are 35-40 percent (2). The cause of
death is most often myocardial infarction. The frequent cardiopulmonary
disease in this population contributes
to increased mortality and decreased
physical reserves necessary for regaining gait with a prosthesis.
Due to the systemic nature of vascular disease, continued risk of losing the
contralateral leg exists. The risk is approximately 20 percent within the two
years following amputation (1,3). The
main determinant of successful rehabilitation following a contralateral lower-limb amputation is successful prosthetic ambulation following the first
amputation (4).
Very often the elderly amputee waits
a long time for the prosthetic leg and
gait training. The usual course for amputee rehabilitation varies, but a fairly
typical process at our medical center is
as follows:
The patient is discharged home postoperatively with follow-up in the surgical clinic. Once the wound heals, the
patient-if considered a suitable candidate-is referred to the amputee clinic
(jointly staffed by orthopedic surgeons
and prosthetists) for prescription of the
preparatory prosthesis. After receiving
a prosthesis, the patient is admitted for
a standard two-week program of gait
training, with continued outpatient follow-up in the amputee clinic.
While waiting for rehabilitation, the
elderly patient's cardiovascular disease
may progress and general deconditioning and further loss of mobility may
occur (5). Long-term rehabilitation becomes more difficult, less successful
and more costly when postsurgical amputation rehabilitation is delayed. For
these reasons, it is imperative that the
unilateral elderly amputee receives
early rehabilitative efforts to maximize
function. Methods to achieve early
prosthetic ambulation and independence are important to improve this
population's quality of life during the
remaining years.
The authors designed a program that
would enroll elderly transtibial (below-knee) amputees postoperatively and
use a multidisciplinary team to begin
active postsurgical amputation rehabilitation early in the recovery process.
It was hypothesized that the time from
surgery to prosthetic ambulation would
be significantly reduced, and patient
satisfaction would increase.
Subjects and Methods
Subjects for the early ambulation program were identified from the daily operating room schedule/log of general
surgery or orthopedic surgery patients
from July 1990 to June 1992. Subjects
were 55 years or older and undergoing
a unilateral transtibial amputation for
vascular disease or complications of
vascular impairment (e.g., nonhealing
ulcers). Subjects with any of the following were excluded: nonambulatory
status prior to surgery (bed-bound,
wheelchair dependent), bilateral extremity amputations or transfemoral
(above-knee) amputations.
The conventional postsurgical care
group consisted of patients 55 years
and older who had undergone a unilateral transtibial amputation for complications of vascular disease at the same
institution from 1986 to 1990. One hundred cases were identified from computerized records of operating room
logs. The charts were reviewed by a
single reviewer (TC). Fifty-six were
recommended for transtibial prostheses. Reasons given for withholding recommendation for prosthesis included
severe heart disease, renal disease and
general debility precluding gait training. The following data were collected
from the medical records for both
groups: medical diagnoses (based on
predetermined criteria) and dates of
admission, surgery, receipt of prosthesis and gait training.
Early Ambulation Program
Subjects were admitted within three
weeks of surgery to the Extended Care
and Rehabilitation Center (ECRC) in
the Durham Veteran's Affairs Hospital
with consent by the patient/caregiver
and approval of the surgical team. Primary medical care was provided by the
ECRC staff (nursing, physical therapy,
pharmacy, social work and geriatric
medicine). Active physical therapy began upon admission with bilateral upper- and lower-extremity exercises and
transfer training for approximately one
hour per day.
When the sutures or skin staples
were removed by the surgical team, the
prosthetist fabricated and applied a rigid removable dressing (RRD). The
RRD or rigid removable plaster cast as
described by Wu (6,7), provides a safe
method to achieve early mobility and
rapid prosthetic fitting among this population. The transtibial plaster cast is
suspended by a stockinette to a supracondylar suspension cuff. Underneath
the transtibial plaster cast, residual
limb socks are added to provide continuous controlled compression (see Figure 1
and Figures 2a
, 2b
, 2c
, and 2d
).
Since the RRD is removable, the
surgical wound can be examined daily.
Knee extension exercises and partial
weightbearing exercises while wearing
the RRD were undertaken using a
theraband. Theraband is a strip of rubberized material supplied at various
tensile strengths to allow progression
with strengthening exercises. The subject was instructed to push the residual
limb into the theraband held between
two hands or stretched between the
wheelchair side-rails. As the limb's
muscle strength and pressure tolerance
improved, new theraband with increased tension would be used.
Subsequent progressive upright
weightbearing on the RRD was begun
by using a platform elevated to the residual limb height for weight shift exercises (see Figure 3
). The RRD was removed daily for examination of the residual limb. When shrinkage of the residual limb stabilized or slowed (determined by the daily number of residual
limb socks), the preparatory prosthesis
was fabricated and daily gait training
started (see Figure 4
). Training continued until the subject was able to don
and doff the prosthesis independently,
ambulate with an assistive walking device (cane or walker) at least 150 feet,
and negotiate stairs.
At approximately 12, 18 and 24
months after discharge from the program, the study subjects were administered telephone questionnaires by an
independent research assistant. Questions regarding hours of prosthetic use,
physical mobility with the prosthesis
and overall satisfaction were included
to determine long-term success of the
program.
Results
Subjects: Of 33 subjects screened for
the early ambulation program, 13 were
excluded for the following reasons: dementia precluding rehabilitative efforts
(2), postsurgical death (2), refusal (1
with cancer, 1 transferred to another
facility), and revision to transfemoral
or bilateral amputation within two
weeks of the original surgery (7). The
remaining 20 comprised the early postsurgical amputation rehabilitation
group.
The early rehabilitation and conventional postoperative care subjects were
all males with mean ages of 66.4 years
(55-80) and 64.9 years (55-79), respectively (see Table 1
). Racial composition was similar. The incidences of specific comorbidities were comparable.
The mean delay from admission to surgery (BKA) is equivalent between the
two groups (see Table 2). All subjects
in the early rehabilitation group successfully completed the program; however, three died soon after discharge.
Among those in the conventional
group, 14 deaths were recorded during
the review period (January 1986-June
1990). The early rehabilitation program patients constituted a relatively
unselected group with many chronic
diseases represented, including mild
cognitive impairment, renal disease,
chronic obstructive lung disease and
cerebrovascular disease.
Time from surgery to prosthesis: The
number of days from surgery to initial
prosthetic fitting is significantly different between groups (see Table 2
):
(mean +/- standard deviation) 65.5 +/-
17.6 days versus 267.9+/-148.5. The
time for gait training in the study group
was compared to the stated "two-week" admission for gait training
among the controls. The longer time
for the study group in gait training may
be because this period was tailored to
the subject's needs without a fixed time
period.
Complications. No complication or
adverse effect resulted from participating in the early rehabilitation program,
including the use of the RRD. One
subject developed an ulcer secondary
to the preparatory prosthesis and required an extended treatment period
of several months. After the ulcer
healed, a second RRD was applied,
and the patient successfully completed
the program to prosthetic ambulation.
Three deaths occurred among the
study subjects after successful completion of the program (45-98 days post-discharge) secondary to cardiovascular
disease and chronic obstructive lung
disease.
Questionnaire: The questionnaire results indicated all surviving study subjects (n 17) were satisfied with the early fit program (see Table 3
). Most participants were wearing their prostheses for
at least six hours per day or "all day."
Only one wore the prosthesis solely for
transfers within the home. Overall, participants were able to independently
transfer within the home with their prostheses. Most were able to negotiate
stairs. A smaller number reported community ambulation (walking outside on
uneven terrain, going to the grocery
store or mall). At any time during the
study, more than half of the participants were able to ambulate within their communities. The majority used a cane as an assistive walking device.
Discussion
This descriptive study demonstrates
that early postoperative amputee rehabilitation reduces the time to achieve
prosthetic ambulation among elderly
dysvascular amputees. The time from
surgery to prosthetic gait training was
clearly reduced without risk of wound
compromise or residual-limb injury
among older patients with systemic
vascular disease.
Early ambulation in the elderly reduces complications such as pneumonia, thromboembolism, residual limb
edema and infection, mortality, loss of
balance and psychological stress (8,9).
The number of deaths within the study
period (three of 20 among study patients and 14 of 56 among controls) illustrates the severity of diffuse vascular
disease. Early prosthetic fit maximizes
independence and hence, the quality of
remaining life (10,11).
As shown in Table 1
, the comorbid
diseases are not significantly different
between the two groups. The equivalent time interval from admission to
time of surgery between the groups
(see Table 2
) suggests no difference between them in preoperative status or
condition (e.g., degree of infection,
pain or cardiopulmonary status). Surgical technique does not appear to have
changed over the study period; all patients underwent the posterior flap
procedure for the transtibial amputation. However, the postsurgical care
programs were very different (i.e., early formal rehabilitation instead of discharge home and follow-up in clinics).
This program allowed prompt rehabilitative efforts, accelerated residual-limb maturation with the RRD (to allow early prosthetic fitting) and expedited receipt of the prothesis.
The RRD has advantages over more
traditional methods, such as elastic
wrappings (soft dressings) or residual
limb shrinkers. Elastic bandages require careful and repeated applications
to avoid distal strangulation and edema. The residual limb shrinker is very
difficult to don and does not protect the
limb from trauma nor allow weightbearing (6).
Other dressings range from immediate-fitted nonremovable plaster casts
to pneumatic devices inflated on the
residual limb. The RRD protects the
residual limb from injury, and daily removal allows close inspection of the
wound and skin integrity. In addition
to reduction of swelling and edema of
the residual limb, use of the RRD allows physical therapy with early
weightbearing, balance exercises and
preservation of the knee joint range to
expedite prosthetic fitting.
This program involved a very select
population: elderly amputees with vascular disease in a Veteran's Affairs
Hospital setting. Malone et al. demonstrated similar positive results of early
rehabilitation for amputees in a VA
setting (12). His study included a wide
range of ages (23-97) and amputation
levels (transphalangeal to hip disarticulation). However, given the prevalence
of vascular disease and common risk
factors among the general population,
similar success could be expected
among the general transtibial amputee
population.
In addition, early postoperative participation in physical therapy provides
an opportunity to determine objectively if the patient is a suitable prosthetic
candidate. The routine discharge home
with outpatient follow-up does not allow this opportunity. Ambulating with
a transtibial prothesis increases energy
requirements by 30 percent (13).
Should the subject be a poor rehabilitation candidate due to decreased motivation or participation, inherent postural difficulties, or diminished cardiopulmonary reserves, the time and cost
of preparatory prosthesis and definitive prosthesis fitting and gait training
could be avoided. Among those who
are cognitively intact and physically
able to don/doff the RRD or who have
an attentive caregiver, the RRD could
be used in the outpatient rehabilitation
setting to further shorten the hospital
stay and maximize time at home for
elderly dysvascular amputees.
Acknowledgments
This study was supported by A. Mellon
Foundation and Charles A. Dana Foundation grants.
TONI M. CUTSON, MD, MHS, is assistant professor in community and family medicine and associate in Medicine/geriatrics at Duke University Medical Center, Box #3003, Durham, NC 27710
DENNIS BONGIORNI, PT, is a physical therapist in the Extended Care and Rehabilitation Center at the Durham Veteran's Affairs Hospital, 508 Fulton St., Durham NC 27705.
JOHN W. MICHAEL, MED, CPO, was director of prosthetics and orthotics, Duke University Medical Center, Box #3003, Durham, NC 27710. He is currently director fo technology at Otto Bock USA, 3000 Xenium Lane, Minneapolis, MN 55441.
GARY KOCHERSBERGER, MD, is assistant profesor in Medicine, Duke University Medical Center, and director fo Extended Care and Rehabilitation Center, Durham Veteran's Affairs Hospital, 508 Fulton St., Durham NC 27705.
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