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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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