Residual Limb Management Starts on the Operating Table

LEIPZIG — Concepts of lower limb amputation and, more specifically,
residual limb management are changing in accordance with a more international
plan focused on restoring function and improving overall care, beginning with
the amputation surgery, a speaker here said.

“In the industrialized countries, still 80% to 90% of amputation is
due to peripheral arterial disease in combination with diabetes mellitus,”
Harmen van der Linde, MD, PhD, said at the 13th ISPO World Congress, adding
that often amputation is delayed. “In such a period, comorbidity and
deterioration may occur.”

  Harmen van der Linde
  Harmen van der Linde

Van der Linde explained that with longer waiting periods, patient
motivation decreases which makes postoperative management more difficult.

“The quality of the surgery is crucial for rehabilitation and the
better the quality of the [residual limb] the fewer problems with postoperative
management, [residual limb] management and prosthetic fitting.”

Van der Linde explained that there is no clear consensus on best methods
of postoperative management. He suggested focusing on the entire patient.
“The first period after surgery, in my opinion, is when we should focus on
general condition and factors related to co-morbidity,” he said.

He also spoke on treating prescription standardization.

“The development of clinical guidelines is of great
importance,” he said. “Further development of existing clinical
guidelines for prescription prosthetics is necessary. There is more expertise
required by international consensus procedures leading to transparent and
standardized prescription.”

Van der Linde concluded that he would like to see changes within the
population of poor performers.

“In many industrialized countries, less than half of the lower limb
amputees are supplied with prostheses,” he said. “Why is is not
known. For future research I would suggest prognostic indicators regarding
patients’ future functioning and … characteristics of patients are
very important.”

Van der Linde suggested increased attention on rehabilitation and
high-technology devices within this population.


I think if we reflect on the trends he talked about I would expect them
all to be relevant within the next 10 to 15 years regardless of which part of
the world you are in.

What really struck me is a theme I am hearing more and more at this
particular meeting, that outcome measures based on the International
Classification of Function (ICF) from the World Health Organization will be the
driver in the future, for prescription, for reimbursement and for personal
clinical competence. That is how our results are going to be measured, not on
the first level, which is dealing with the loss of physical function, but
increasingly on the second level which is what activities can the person
perform. Ultimately we’ll all be measured on the third level, which is how
well they participate in life.

We are moving toward a quality of life standard and part of that will
include long-term costs to the health care system, so I think a smart CPO is
going to start learning as much as he or she can about the ICF classification,
about the data sets being developed and about the implications for the future.
It will not all be about technology. It will be about patient participation in
meaningful activities in their culture. I think if you focus on empowering
patients to be included in society, that’s what we do anyway.

It resonated very strongly with me that pre-prosthetic focus should not
be on the residual limb but be on the abilities of the patient —
especially with the elderly multiple-comorbidity cohort, who is our routine
patient now. He is absolutely right: If they spend 12 weeks delaying the
amputation, in bed, in pain, they are so debilitated that it is almost
impossible to function at the level they had 3 months ago. If you let them go
another 3 months while you argue with the health care authorities, you’ve
almost guaranteed they won’t succeed. I think an aggressive, comprehensive
rehab program even before the amputation has been decided, I think would pay
tremendous social dividends.

His focus on poor performers is absolutely stellar. I don’t know
how we are going to solve the problem. I am embarrassed and disappointed to
admit that less than half of the amputees in the United States have the chance
to try a prosthesis. We are doing no better than the rest of the world. If we
could more effectively take care of the poor performers, then I think we could
begin to reach into the non-performers.

— John Michael, CPO, FAAOP
President, CPO
Services Inc. and Member, O&P Business News Advisory Council.

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