Amputation of a limb is a major event for an individual and can result in significant psychological difficulties as they undergo rehabilitation, get fitted for a prosthetic limb and learn to walk effectively again. The surgical planning has to be done with the aim that the patient can easily and comfortably wear the prosthesis, engage fully and speedily in rehabilitation and have a reduced level of energy expenditure when they are walking. Patients in this situation have a lot to learn - to get the prosthesis on and off, to check the skin for pressure areas, to walk on surfaces of varying difficulty and to manage the times when the prosthesis is off.
A skilled and experienced team is required to teach the patient all the knowledge and skills they need for maximum independence and this includes the surgeon and his team, the medical advisers, the prosthetist, an occupational therapist, the physiotherapist and employment and social facilitators. Lower limb amputations are increasing as the populations of industrialised countries continue to age and with that the main reason for amputation, peripheral vascular disease. The ratio of below knee amputations to above knee amputations has changed as surgical skills for keeping the knee joint have increased, leading to the present occurrence of 70% below knee.
Peripheral vascular disease (PVD) is the most common reason for amputation with a significant number of patients suffering an amputation on the other side within three years. Most patients are elderly and have ischaemic problems which are secondary to diabetes, with peripheral neuropathy a common difficulty which can lead to ulcers and gangrenous changes. Trauma to the lower limb which involves the arteries and nerves can be treated but may result in a leg which is painful and does not function well, meaning that an amputation would be preferable for speedy rehabilitation and return to normality.
Amputation is also employed for less common conditions such as infections, congenital lower leg abnormalities and tumours. The planning for an amputation should be viewed as an operation targeted at reconstruction and not just removing a body part, aiming for the planned independence and function of the patient. As the level of the amputation progresses up the leg this increases the work of walking, requiring increased levels of oxygen concentration, increased expenditure of energy levels and reducing the speed the person is able to walk. Below knee amputation shows little increase in energy needed for walking but mid thigh can increase this by fifty percent.
The energy load of walking may be very important as many patients who undergo amputation suffer from peripheral vascular disease and may have other medical disorders, all meaning that much of their reduced energy may be consumed in walking. This means that getting sufficient strength and walking ability to attain functional independence may be difficult. Healing after amputation is not a foregone conclusion due to the likely reason for the operation being poor circulation, and the condition of the skin exerts an important influence over the overall functional outcome for the patient. The soft tissues around the amputation site function as the connection between the prosthesis and the leg.
The amputation stump region must be large enough and the tissues be of good enough quality to allow effective gait by transmitting the lengthways and shearing forces which will be transmitted through it from the socket of the new leg. Direct weight bearing on the end of the stump can occur in amputations which are performed through a joint such as the knee and the ankle, but this style of amputation has its difficulties. The new knee joint is inevitably formed below the level of the old one, causing the knee to stick out obviously further than a normal knee and the calf to be correspondingly shorter.
Effective walking requires the soft tissues of the stump of the limb to be big enough and of high enough quality to manage the shearing and lengthways forces applied to it by its close apposition to the prosthesis socket. The end of the leg can bear the stresses directly in a lengthways direction in those amputations through the joints such as the ankle and the knee, though this type of amputation can present problems. The prosthetic knee joint has to be formed below the level of the original and this forces the knee to project further than a normal knee and so makes the calf significantly shorter. - 14130
A skilled and experienced team is required to teach the patient all the knowledge and skills they need for maximum independence and this includes the surgeon and his team, the medical advisers, the prosthetist, an occupational therapist, the physiotherapist and employment and social facilitators. Lower limb amputations are increasing as the populations of industrialised countries continue to age and with that the main reason for amputation, peripheral vascular disease. The ratio of below knee amputations to above knee amputations has changed as surgical skills for keeping the knee joint have increased, leading to the present occurrence of 70% below knee.
Peripheral vascular disease (PVD) is the most common reason for amputation with a significant number of patients suffering an amputation on the other side within three years. Most patients are elderly and have ischaemic problems which are secondary to diabetes, with peripheral neuropathy a common difficulty which can lead to ulcers and gangrenous changes. Trauma to the lower limb which involves the arteries and nerves can be treated but may result in a leg which is painful and does not function well, meaning that an amputation would be preferable for speedy rehabilitation and return to normality.
Amputation is also employed for less common conditions such as infections, congenital lower leg abnormalities and tumours. The planning for an amputation should be viewed as an operation targeted at reconstruction and not just removing a body part, aiming for the planned independence and function of the patient. As the level of the amputation progresses up the leg this increases the work of walking, requiring increased levels of oxygen concentration, increased expenditure of energy levels and reducing the speed the person is able to walk. Below knee amputation shows little increase in energy needed for walking but mid thigh can increase this by fifty percent.
The energy load of walking may be very important as many patients who undergo amputation suffer from peripheral vascular disease and may have other medical disorders, all meaning that much of their reduced energy may be consumed in walking. This means that getting sufficient strength and walking ability to attain functional independence may be difficult. Healing after amputation is not a foregone conclusion due to the likely reason for the operation being poor circulation, and the condition of the skin exerts an important influence over the overall functional outcome for the patient. The soft tissues around the amputation site function as the connection between the prosthesis and the leg.
The amputation stump region must be large enough and the tissues be of good enough quality to allow effective gait by transmitting the lengthways and shearing forces which will be transmitted through it from the socket of the new leg. Direct weight bearing on the end of the stump can occur in amputations which are performed through a joint such as the knee and the ankle, but this style of amputation has its difficulties. The new knee joint is inevitably formed below the level of the old one, causing the knee to stick out obviously further than a normal knee and the calf to be correspondingly shorter.
Effective walking requires the soft tissues of the stump of the limb to be big enough and of high enough quality to manage the shearing and lengthways forces applied to it by its close apposition to the prosthesis socket. The end of the leg can bear the stresses directly in a lengthways direction in those amputations through the joints such as the ankle and the knee, though this type of amputation can present problems. The prosthetic knee joint has to be formed below the level of the original and this forces the knee to project further than a normal knee and so makes the calf significantly shorter. - 14130
About the Author:
Jonathan Blood Smyth, editor of the Physiotherapy Site, writes articles about Physiotherapy, back pain, orthopaedic conditions, neck pain, injury management and physiotherapists in London. Jonathan is a superintendant physiotherapist at an NHS hospital in the South-West of the UK.
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