Limb amputation

Amputation should not be associated with the end of life. Certainly man faces new challenges, but they are all solvable. Those who have had an amputation can regain their mobility with prostheses and by observing certain rules.

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One of the problems that can occur in amputees is residual limb swelling. It can arise from general causes such as circulatory and/or metabolic disorders, including circulatory failure, protein and/or electrolyte imbalances, renal dysfunction and local lesions. Regarding the latter, it should be noted that an increase in local blood flow against the background of postoperative wound healing after amputation is often a contributing factor. Such swellings are limited and stay within certain limits. If these are exceeded, one or even several other causes must be sought.

Local edema can occur in the area of foreign bodies: sutures or bandages, non-viable limb tissue, prosthetic sleeves, etc., which the human body tries to envelop with connective tissue and thus isolates and rejects. The position of the stump is important. In the absence of external compression, the low position of the residual limb contributes to the formation of edema, which is most pronounced in the distal area.

Local edema can be caused by superficial or deep wound infections, skin diseases, obstruction of normal lymphatic and/or blood flow. It should be noted that the venous outflow is passive and indirectly promoted by muscle contractions. In the amputated residual limb, even with myoplastic coverage, muscle contraction is not as active as in the intact residual limb. In addition, varicose veins, a history of vascular thrombosis, fibrosis after radiation and postoperative scars in the groin and tendon fossa in this area can also have a negative effect. External pressure (tight bandage, bandage or prosthetic cuff) has a similar effect. Even a slightly noticeable ligature can lead to residual swelling of the limb weeks or months later. It is important to distribute the pressure on the residual limb so that it decreases from distal to proximal. This not only prevents the development of chronic edema, but also improves the conditions for the free outflow of lymph and venous blood.

Reconstructive surgery on residual limbs

Reconstructive surgeries on atrophied upper and lower limbs are performed to correct various deformities and/or diseases and to increase the functionality of the shortened hand/limb.

The currently most frequently performed procedure is the so-called skin-plastic stump surgery. When considering skin grafting, it is important to determine exactly how and to what extent the area will be exposed during use of the prosthesis and whether the proposed skin grafting method can provide functional coverage, as not all skin grafting procedures meet this requirement.

For example, abrasions and ulcers are quite common due to the incomplete nature of free grafts, particularly in lower limb residual limbs. For this reason, specialists only recommend this type of reconstruction as a temporary closure of the amputation wound, in order to enable later high-quality skin and plastic reconstruction of the residual limb.

The skin of a residual limb that has been repaired with a flap on a provisional splint (Hairstalk/Philat) is also considered non-functional, since neither the blood flow nor the innervation in the residual limb are completely normal, even over a longer period of time. The result is frequent ulceration of the skin in the areas of concentrated pressure.

Another possibility is skin plication with complex flaps on the vascular/kidney pedicle. This can be used for extensive skin damage on the residual limb and upper extremity segment. The functional properties of this type of flap are also poor. Skin reconstructed using local plastic techniques is the most resilient in this regard. However, it should be clarified that relatively small butt defects can be repaired with traditional surgery of this type.

Movement therapy after amputation

Lack of exercise can lead to spasticity and contractures. The following exercises are indicated to prevent the consequences:

• In the starting supinated position, push the limbs back and raise them as high as possible. Hold the body in this position for 5-10 seconds;
• When coming out of the supinated position, perform a similar exercise but raise your legs forward. Make sure the sound leg is not bent at the knee;
• in the starting position, lying on your side on the sound leg, raise the residual limb for 10 seconds.

Each exercise should be performed 5 or more times. Increase the physical load and exercise time every day. In addition, it makes sense to lie down on a flat surface for up to 15 minutes and briefly move the residual limb to the side.

How to prevent the development of complications?

It is important to exercise daily because hypotrophy makes it difficult to use the prosthesis and move around. An exercise program will positively affect residual limb formation, reduce swelling, and improve trophic support.

Treatment of the stump on the foot – is a demanding procedure that requires a lot of manipulations that require skill, knowledge and time. Our medical staff is ready to help elderly people who have undergone surgery to adapt quickly and prevent the development of complications.

Over and beyond Pension for the elderly the following services:

• medical care;
• adequate nutrition;
• temporary or permanent residence;
• hygiene services;
• Free time activities;
• rehabilitation measures.

Experienced professionals will help you overcome temporary difficulties in your life and improve your quality of life.

Tips for patients who have suffered an amputation and use prostheses

An amputation is a serious event that changes the life of the affected person significantly. Thanks to technological advances, it is now possible for these people to maintain their social status and ability to take care of themselves despite losing an arm or leg. However, you must be aware that a properly formed residual limb and the selection of an appropriate prosthesis are vital.

Postoperative complications such as non-healing, recurring ulcers, wound infections, impairment of local blood circulation and local sensitivity, phantom pain, residual limb deformities and restricted mobility, so-called contractures, can make effective prosthesis care considerably more difficult and in some cases even prevent it. Contractures in this category of patients usually develop due to prolonged immobility and muscle weakness.

Therefore, it is very important that the patient takes the doctor's recommendations seriously and strictly follows them during the rehabilitation period. In particular, he should take care of the postoperative suture and take care to shape the residual limb, maintain joint mobility and strengthen the muscles that are still present.

Daily care of the residual limb wound should include alternating shower, washing the wound with baby soap and drying the residual limb with a soft towel after water treatment. Very helpful for restoring local blood circulation is a gentle massage, which also helps to restore skin sensitivity and the central nervous system's adaptation to the absence of the residual limb, which is one of the measures to combat the so-called phantom pain.

An important problem in the postoperative period is the swelling that occurs after the operation. It is the human body's natural response to surgery and usually resolves in a week or two. If this is not the case and the swelling does not go down, treatment includes elastic bandages and lymphatic drainage massages, which are only performed by an experienced specialist.

Treatment of pain in amputated limbs

Amputees suffer from two types of pain syndromes: residual limb pain and phantom limb pain.

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Stump pain and phantom limb pain have different causes and are not related. The prevalence of phantom pain is up to 75-85 %, that of residual limb pain 60-70 %.

A common cause of residual limb pain is neurofibromas, which are nodular growths at the end of the nerve. Surgeons cut them out, but the pain doesn't always go away. If the surgical treatment is unsuccessful, the patient is referred to the pain management clinic. Phantom pain is related to brain activity and treating it is challenging.

Pain treatment for amputees at Ilya Hospital is:

In Russia, there is no specific term for a pain management specialist. Abroad, the discipline is called pain management – overcoming pain. At Ilya Hospital, anesthesiologists work alongside surgeons, neurologists, physical therapists and psychotherapists to treat pain in amputees. This collaboration enables our specialists to make responsible and scientifically sound decisions when examining and treating patients. In their practice, our doctors follow the current international guidelines and choose the best treatment method for each individual case.

We use the latest and safest drugs with proven effectiveness. Patients with residual limb pain are initially treated with drugs that alter the levels of neurotransmitters that slow nerve impulses and block pain sensation in the brain. If this treatment does not work, narcotic pain relievers are used.

phantom pain

Most people experience phantom limb pain from time to time. The phantom is not the presence of pain itself, but its location - the amputated limb. Peripheral and central factors are believed to be involved in this mechanism. The onset and duration of pain is usually observed within a few days after amputation, but can also occur over several months to years. The following terms are used to describe phantom limb pain: tingling, stabbing, stinging, throbbing, burning, pain, pinching, squeezing and 'squeezing'.

Phantom pain is often more pronounced immediately after the amputation and then decreases over time. Postoperative desensitization therapy is recommended to reduce pain during the initial period of prosthesis loading. Many patients experience phantom pain more frequently when the prosthesis is removed, e.g. B. at night. The risk of this type of pain is reduced if both spinal and general anesthesia are used during the procedure.

Other non-pharmacological treatments may also be prescribed for pain relief, including transcutaneous electrical nerve stimulation (TENS), acupuncture, and spinal cord stimulation.

phantom sensations

Most patients have phantom sensations that give the impression that the amputated part is still there. Phantom sensations should not be interpreted as phantom pain Phantom pain More than 70% of % amputees suffer from residual limb pain, which can severely limit their function, impair their quality of life and significantly complicate the amputation process. Read more . Phantom limb pain can be a problem, particularly for patients with lower limb amputations, when they wake up at night to go to the bathroom. Thinking their limb is still in place, they take a step and fall or damage the rest of the limb. To avoid injury, a splint can be worn while sleeping.

Often the history and physical examination are sufficient to evaluate patients with residual limb pain, but sometimes investigations are needed.

Pain associated with skin changes (eg, erythema, ulceration) indicates skin irritation or infection. Diffuse, painful, and tender erythema suggest panniculitis. In patients with a history of vascular disease, the ulceration may also be due to recurrent ischemia.

Persistent pain without skin lesions suggests neuropathy, complex regional pain syndrome, deep tissue infection, and, in patients with a history of vascular disease, recurrent ischemia. Pain exacerbated by pressure and/or systemic symptoms (eg, malaise, fever, tachycardia) may indicate deep tissue infection.

Intermittent pain without skin lesions, occurring during use of the prosthesis and disappearing when the prosthesis is removed, indicates implantation problems, a neuroblastoma, or a bone spur. Dysesthesia and/or a neuropathic quality of pain indicate a neuroma. Recurrent pain unrelated to prosthesis use and without skin lesions suggests several primary causes, including neuroblastoma, dysfunctional muscular atrophy with trophic changes in the vessels, impaired blood supply, and deep bone pain suggesting exposure bone marrow sites.

Skin integrity disorders

Skin integrity is usually compromised by pressure and/or friction on the skin, particularly when pressure is applied from above and below or along the sides of the skin's surface. The risk increases when the skin is wet or damp (e.g. when sweating).

The first sign of skin deterioration is redness and a burning sensation, which may be accompanied by pain, swelling, blistering, and ulcers. Continued wearing of the prosthesis will cause more serious skin damage and may lead to the development of a skin infection.

Although skin damage cannot be avoided completely, certain measures can help prevent or delay its occurrence:

Maintaining the hygiene of the residual limb. This includes washing the residual limb with a mild soap and rinsing it thoroughly twice a day (more often for those who sweat more than normal); the prosthetist can recommend antiperspirants that have been specially developed for prosthesis wearers

Maintaining a stable body weight: This is the best way to ensure a good fit of the prosthesis on the body; even small changes in body weight can affect the fit

Eating a healthy diet and drinking water throughout the day: This helps control weight and maintain healthy skin.

If signs of skin integrity are noted, the prosthetist should be contacted immediately and the prosthesis adjusted if necessary. In such cases, wearing the prosthesis should be avoided if possible until it is fitted. If the prosthesis is not the cause or fitting does not correct the problem, a medical evaluation should be performed.

infection of the skin

Normally, in dry, intact skin, bacteria and fungi coexist in equilibrium. However, the interlayer (a type of gel layer or plastic) that adheres to the skin of the residual limb creates a warm, moist environment that encourages the growth of bacteria and fungi, which can lead to the development of an infection. Wet skin also tends to crack, which makes it easier for bacteria to enter the body. This can spread the infection.

Symptoms of infection include soreness, redness, ulceration, and purulent discharge. An unpleasant odor may indicate infection or poor hygiene. When a mild bacterial infection develops into mucus, mucus is a common bacterial infection of the skin and subcutaneous tissue. The infection is usually caused by streptococci or staphylococci. It causes redness, pain, and tenderness. Read more Folliculitis and skin abscesses Folliculitis and skin abscesses are pus-filled cavities in the skin caused by a bacterial infection. They can be superficial or deep and affect only the hair follicles. Read more There may be fever and a deterioration in general well-being.

Any symptom of infection should be reported to your doctor. The following symptoms should be treated immediately to prevent the infection from developing into a life-threatening condition:

Treatment of a bacterial infection usually consists of local hygiene and topical antibiotics. Sometimes dead skin removal, oral antibiotics, or both are needed. As a general rule, the prosthesis should not be worn until the skin infection has cleared.

Sciatica residual edema - treatment in Germany

Causes of residual limb edema

Stump edema is one of the problems that can occur in amputees. It can arise from general causes such as circulatory and/or metabolic disorders, including circulatory insufficiency, protein and/or electrolyte disorders, renal dysfunction, and local lesions. Regarding the latter, it should be noted that an increase in local blood flow against the background of the healing process of the postoperative wound after amputation often contributes to it. Such swellings are inherently limited and within certain limits. If these are exceeded, one or even several other causes must be sought.

Local edema can occur in the area of foreign bodies: sutures or bandages, non-viable limb tissue, prosthetic sleeves, etc., which the human body tries to envelop with connective tissue and thus isolates and rejects. The position of the stump is important. In the absence of external compression, the low position of the residual limb contributes to the formation of edema, which is most pronounced in the distal area.

Local edema can be caused by superficial or deep wound infection, skin disease, and the presence of an obstruction to normal lymph and/or blood flow. It should be noted that the venous outflow is passive and indirectly facilitated by muscle contractions. In the amputated residual limb, even with myoplastic coverage, muscle contraction is not as active as in the intact residual limb. In addition, varicose veins, a history of vascular thrombosis, fibrosis after radiation therapy and postoperative scars in the groin and tendon pits can have an additional negative effect in this area. External pressure (tight bandage, bandage or prosthetic cuff) has a similar effect. Even a slightly noticeable ligature can lead to residual swelling of the limb weeks or months later. It is important to distribute the pressure on the residual limb so that it decreases from distal to proximal. This not only prevents the development of chronic edema, but also improves the conditions for the free outflow of lymph and venous blood.

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General recommendations

In addition to the exercises to shape the residual limb, the patient should be prepared for the prosthetic fitting. This preparation should begin as soon as possible after discharge from the hospital. During the hospital stay, the patient is referred to a physical therapist, physiotherapist, and prosthetist for general advice and monitoring.

What to do to get maximum mobility and activity?

• Perform the recommended general physical exercises to maintain the muscles. Therapeutic gymnastics can be started under medical supervision on the first or second day after the operation.
• Don't forget to exercise the muscles of the butt as well.
• It is important that you maintain an upright posture. On the 5th or 6th day, you should try to stand on crutches. Walking on crutches helps overcome problems related to poor coordination and loss of balance.
• It is important to train the back muscles. Amputated limbs are subjected to increased stress. Without proper training, the lumbar spine bends, causing problems with both your back and walking on a prosthesis. Pull-ups on a bar, push-ups and wall bars are good for your back.
• See a doctor to detect the development of negative effects of the amputation - tissue infiltration, osteoporosis, swelling, etc.

If concomitant diseases are present, it is important to achieve compensation and stabilization of the general condition.

Why prosthetics shouldn't be rushed

The preparation time for prosthetics varies from patient to patient. Some patients are already able to wear a prosthesis two to three months after the amputation. Others need between one and one and a half years. You should see an orthotist as early as possible and not wait too long. However, there is no reason to rush into wearing a prosthesis until the residual limb is fully formed.

A residual limb is ready to wear a prosthesis when it

• it is conical and has a mobile scar without adhesions;
• is painless on deep palpation;
• has mobility in the joints;
• has functioning muscles.

This is a condition that must be achieved in order to quickly and easily fit a prosthetic leg and return to an active life. This can be achieved through the patient's own positivity, regular effort and activity, and support from family members and physicians.

• What to do with amputated limbs?.
• The reamputation is.
• Life after a leg amputation.
• blunt.
• Indications for amputation.
• acetabulum.
• The toe formation.
• prosthetic legs.