Putting the Patient in Charge: Maintaining the Residual Limb

The health and healing of the residual limb following amputation depends as much on the patient’s commitment to the recovery process as it does to the surgeon’s and practitioner’s knowledge and performance. To successfully transfer the responsibilities that encompass the lifelong process of limb maintenance, practitioners must communicate clearly and consistently and exercise an ample amount of patience.

Heikki Uustal, MD, explained the mindset of the novice amputee as it pertains to the healing process.

“Unless they have been through amputation previously they need to learn everything from square one,” Uustal said. “Even though we have seen thousands of patients and it is very routine, unless you explain it to the patient frequently, they are not going to understand.”

Uustal is not underestimating patient comprehension, but instead calling attention to the need for proper patient education, which might mean slowing the teaching process or repetitive training.

Consistency is important throughout the phases of treatment and training, explained William Ertl, MD.

“Their limb is dynamic and the health and recovery of that limb is really going to be up to them,” he said. “It is incumbent on them to treat that limb like an organ … and so they need to care for it on a regular basis.”

For patients to take responsibility, they need to recognize their role in the process and the part they play in the short and long-term health, healing and maintenance of the residual limb.

Timeframe of changes

The several months following amputation can bring significant changes to the residual limb. Explaining those expectations to your patients is critical for successful recovery. While each patient’s recuperation will differ, it is essential to inform them of a general timeline of events and also of limb changes they will experience within the first few months after amputation.

“Once the incision is healed they should expect some remodeling of the initial [residual limb],” Christian Ertl, MD, FACS said. Up until the 3-month mark “muscles will atrophy a little bit, the swelling will hopefully go down and they should expect that things will remodel.”

The healed incision will begin to scar, which will result in a thicker layer of skin when compared to the surrounding tissues. Also, let them know that a certain amount of volume loss is to be expected as the swelling decreases and edema is managed.

“If they are going to be discharged from the hospital they are going to be responsible for dressing changes, … nutrition, … edema control,” Uustal said. “So we educate the patients on at least those three different areas … and what part they are going to play.”

Pain problems

While you are discussing the timeline of events with your patients, it might be wise to also address the issue of pain following amputation. Uustal discusses with his patients appropriate management of phantom sensation, residual limb and phantom limb pain.

“I always review with them about differences and types of pain that they might feel at the very beginning,” Uustal told O&P Business News.

Similarly, William Ertl explained the significant pain component to his patients and also prescribes narcotic pain relievers when necessary, but asks patients to stay away from anti-inflammatory medications.

“We are trying to form a bone bridge and there is no hard evidence to show that an anti-inflammatory will retard bone healing. But there are some animal and cellular evidence that maybe an anti-inflammatory will slow down bone healing so early I try to tell them to be patient,” William Ertl said.

Skin issues

As you move forward in the healing process toward prosthetic fitting, encourage patients to become familiar with their residual limb and aware of their skin tolerance.

“Educating the patients to recognize what is acceptable and what is not acceptable as far as skin problems is a big part of what I do as a physician, what the therapists should do, and what the prosthetists should do,” Uustal said.

The next step in his process, Uustal explained, is giving patients a prosthesis wearing schedule to build up a tolerance to eventually full-time wear.

“We can all do a great job preparing the patient for the first month and then we give them the prosthetic device. If we don’t give them instructions on how long to wear it, how to inspect their skin, how much walking they can do, it is very easy for the patient to fail within the first few days by wearing it too much or not putting it on or [taking it] off properly,” Uustal said.

The wearing schedule should be patient-specific given different factors including pre-existing health conditions, age and early skin tolerance.

Existing Conditions and Recovery

Existing medical conditions and age play a role in the recovery process and overall maintenance of the residual limb.

“[Patients] need to be aware of the fact that something led to the loss of that limb,” Kevin Carroll explained. “There may be a lifestyle change that they need to take into consideration.”

After undergoing amputation, diabetic patients may assume the worst is behind them, and neglect their overall health. They need to do just the opposite. Diabetic patients should be reminded that they are still at risk for future amputation if they do not manage the disease as prescribed by a physician.

Proper nutrition is essential for the growing number of diabetic amputees and can have a significant impact on wound healing, William Ertl said.

Christian Ertl echoes those warnings, explaining that people with peripheral vascular disease or diabetes will remain at risk for further amputation indefinitely as well as an increased risk of a host of other medical maladies.

“A diabetic smoker’s risk of vascular disease and heart disease is 200 to 400 times normal,” Christian Ertl said. “A diabetic will actually start developing circulation problems and heart disease ten years earlier than everybody else.”

Carroll explained that when it comes to the sound leg and the residual limb, the focus is on prevention and long-term healthy maintenance.


Breakdown and irritation

Skin breakdown and irritation are two early indications that either skin tolerance is not advanced enough for the wearing time or that there is an underlying problem with the fit of the device itself. Patients should visit with their prosthetist at the first sign of skin breakdown, irritation, or any change which inhibits prosthesis use. Early intervention will often alleviate the cause of the irritation before it worsens.

Common skin issues are redness, blisters and abrasions. Make sure the patient understands that regardless of fit, there will be an area of redness from wearing the prosthesis for long periods of time and instruct them to contact you when this redness becomes bothersome, or lasts for more than 15 minutes after prosthesis removal, Uustal suggested.

Abrasions are often caused by friction within the socket, according to Kevin Carroll MS, CP, FAAOP and vice president of prosthetics for Hanger Orthopedic Group. Locating the source of the friction is necessary to treat the cause and alleviate future pain.

“There is good friction and there is bad friction. Good friction holds the prosthesis in place with rotational stability,” Carroll told O&P Business News. “Bad friction is over the bony areas so we have to determine how to manage friction within the prosthesis.”

Patients should be instructed to perform daily limb maintenance to find irregularities and become more familiar with the limb as it changes over time.

Chronic area of ulceration above the scar Chronic ulcer that is scarred over from constant rubbing on the patient’s prosthesis Example of the effects of dry skin from lack of moisturizing, coupled with overuse of betadine to wash/scrub Close monitoring of new amputation is necessary to avoid infection
1. Chronic area of ulceration above the scar, centrally located it shows a chronic “furunculitis” – like a razor burn, this is from the patient’s scar folding over the skin. 2. A chronic ulcer that is scarred over from constant rubbing on the patient’s prosthesis. 3. Example of the effects of dry skin from lack of moisturizing, coupled with overuse of betadine to wash/scrub. 4. Close monitoring of new amputation is necessary to avoid infection.
Images 1-3 reprinted with permission of Christian Ertl. Image 4 reprinted with permission of Heikki Uustal.

Perspiration and volume changes

Another cause for skin irritation is perspiration. A build-up of moisture within the prosthetic sock or device can cause unnecessary damage to the limb that can take weeks to heal, thereby limiting prosthesis use.

Rash-like irritations do not take long to develop — sometimes in only 1 to 2 hours — which means patients need to understand that the first layer of material next to the skin should be removed at the first sign of excessive wetness and replaced with something clean and dry, Uustal explained.

In some cases perspiration can be controlled with medication or over-the-counter antiperspirants. In addition, all prosthetic users should be well versed on proper component and residual limb cleaning, especially those concerned with perspiration.

Conversely, excessive dryness, Carroll explained, can cause even more problems than moisture, including cracked skin and increased breakdown.

Limb volume is always critical and commonly in flux. It is important to stress this to your patients early on, because they may not understand the way that weight gain and loss will affect their prosthetic components. Weight gain or loss can cause irritating rubbing and affect the stability of the limb fit.

Physical training

Easing back into physical activity following amputation commonly starts within days of surgery to avoid muscle atrophy and ultimately build the tone necessary to use a prosthesis.

“The limb that has the amputation must be as strong as, or stronger than, it was prior to amputation,” Uustal said. “If we are anticipating that our patients are going to have 2 to 4 weeks of healing time waiting for their prosthesis, their muscles are getting weaker and weaker — they can lose 50% or more of their strength.”

William Ertl suggests patients perform isometric contractions 4 weeks into the healing process and throughout life.

This will help “to maintain the health of that limb especially in diabetic patients who may have a component of vascular disease,” William Ertl told O&P Business News.

Enforce the idea that your patients play a role in their recovery and explain the importance that they perform the exercises recommended.

Similarly, Christian Ertl encourages patients to use it or lose it.

Muscles don’t grow strong overnight, Christian Ertl said. “It takes awhile. By exercising the muscles and getting the muscles to squeeze and pump, you get circulation. It is going to improve healing and blood return through the veins back through that extremity, which will help the swelling.”

Building up specific muscle groups will also aid in prosthesis use and stabilization as a patient becomes accustomed to using a device. Uustal explained that many transtibial amputees will find that they need added upper body support to use a cane or other walking device while they are learning to use their prosthesis.

“For a [transtibial] amputee, their gait is mostly in their thigh muscles now and for [transfemoral amputees] their gait is mostly in the hips and pelvis — they have to swing the leg forward,” Christian Ertl said.

While patients may not be able to build up the same muscle mass they previously had, they will find this physical strength training invaluable as they evolve with their prosthesis.

Overall health

Exercising the muscle improves circulation and healing
Exercising the muscle improves circulation and healing.
Image reprinted with permission of Hanger Orthopedic Group Inc.

Localized treatment and attention will only take a person with amputation so far. Patients need to be aware of the role their overall health will play in the long-term maintenance of the residual limb.

“Their recovery can be improved in a great way if we also improve their general health,” William Ertl said.

In addition to increased strength training and aerobic activity, patients need to be aware of the overall needs of their body and take control of any bad habits, such as smoking.

Obesity creates additional problems for the amputee in terms of conditioning and training and only becomes harder to overcome over time. Traumatic amputees are obviously left with few options in terms of pre-amputation intervention but those with pre-existing conditions that increase their susceptibility to amputation should take the appropriate steps to get their weight under control.

Anticipate change

Above all else, practitioners should make sure their patients know that they are available to answer questions at any time before or following amputation.

“I would much rather have the patient call me … early on so we can fix a small problem and we can continue with the progression, than wait until there is a big problem — especially a blister or a skin ulceration that now will take a month to heal,” Uustal said.

The residual limb will change over time and the patient should know how to assess their skin and prosthesis fitting to observe those changes and report problems. As the prosthetist, you should encourage this involvement and recommend follow-up appointments as needed.

Following this routine with patients can become cumbersome over time but it is important to engage with each new patient like your first.

“I try to get the patient involved to show that they have power and control over their recovery process,” William Ertl said offering another word of advice — “Stay motivated so the patient stays motivated.”

Jennifer Hoydicz is a staff writer for O&P Business News.

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