Introduction[edit | edit source]As with any surgery, having an amputation carries a risk of complications. Surgeons will aim to reconstruct the limb to the best of their ability, taking into account soft tissue viability, bone length and other anatomical considerations. However, underlying disease state and post-operative management can result in complications, the most common of which are: Show
Oedema[edit | edit source]Stump oedema occurs as a result of trauma and the mishandling of tissues during
surgery [2]. After the amputation, there is an imbalance between fluid transfer across the capillary membranes and lymphatic reabsorption [3]. This, in combination with reduced muscle tone and inactivity,
can lead to stump oedema. The complications that can arise from stump oedema include wound breakdown, pain, reduced mobility and difficulties with prosthetic fitting.[4] Numerous interventions are used to manage and prevent post-operative stump oedema, including, compression socks, rigid removable dressings, exercise, wheelchair stump boards, and PPAM aiding. The BACPAR post operative oedema guidance (2012) details the evidence behind these interventions and recommends the use of rigid removable dressings where expertise, time and resources allow. Also according to this guideline the PPAM aid, stump boards, and compression socks have some evidence for oedema control but it is not their main function. [5] See Acute post-surgical management of the amputee for more information. Wounds and Infection[edit | edit source]Surgical site infection after amputation is common and as well as increasing patient morbidity, can have negative effects on healing, phantom pain and time to prosthetic fitting [6]. Risk factors for a stump infection include diabetes mellitus, old age and smoking, which are all common denominators amongst the amputee population [7]. The decision to insert a drain and use clips instead of sutures is also associated with increased infection risk. Literature suggests a post-operative infection rate ranging from 12-70% in the UK
[7] but this is widely due to the variation in the classification of stump wounds. The Centre for Disease Control (CDC) Surgical Site Infection (SSI) Criteria (2008) aims to make this classification more
standardised[8]:
The potential consequences of infection include vac therapy, wound debridement and revision surgery. This can increase hospital length of stay and the risk of secondary morbidities such as pneumonia or reduced function. Wounds should be inspected regularly so that any signs of infection can be detected. The wound may also open up along the surgical line (dehiscence). This happens when the wound is not strong enough to resist the forces placed on it and could result in muscle and bone is exposed. These forces include a direct fall (most common), trauma, or shearing. Other causes may include removing the sutures too soon or swelling of the residual limb. Surgical intervention is usually indicated with total dehiscence. [9] The following types of wounds may be encountered: Tissue Necrosis[edit | edit source]Poor tissue perfusion leads to ischaemia and necrosis. Dusky skin changes, mottled discolouration and slough can be observed. This can lead to subsequent wound breakdown and dehiscence
[9]. Depending on the extent of non-viable tissue, wound debridement or revision surgery is often necessary. Skin Blisters[edit | edit source]Wound oedema, reduced elasticity or tight stump dressings, and adhesive dressings applied with tension can all increase the friction of the epidermis and cause blistering of the skin. Blisters can also be formed due to infection, traction, and an allergic reaction. [9] Sinuses and Osteomyelitis[edit | edit source]A deep, infected sinus can often mask osteomyelitis and delay healing. The sinus can extend from the skin to the subcutaneous tissues and management often includes aggressive antibiotic therapy. Sometimes, surgery is an option, however, this can impact on the shape of the stump
and rehabilitation outcomes [9] More information on wound healing following lower limb amputation from The American Academy of Orthotists & Prosthetists. Pain[edit | edit source]Pain is an inevitable consequence of amputation. There are several types of sensations following an amputation that should be discussed when referring to pain following amputation. Some of them are extremely painful and terribly unpleasant; some are simply weird or disconcerting. In one form or another, they are experienced by most people following an amputation. Post amputation pain can be isolated to the residual limb or can occur as phantom pain. For many, the pain will not just result from the trauma of the surgery, but will also include a neuropathic presentation known as phantom limb pain (PLP). When amputation has resulted from a traumatic incident, such as in a disaster setting, this can be complicated by co-existing injury to the same limb or other parts of the body. For the physiotherapists involved in the early and post acute stages of rehabilitation, the challenge is determining the nociceptive and neuropathic causes which require attention in order to manage the patient and so enable effective rehabilitation to occur.
In addition to these 4 pain types that can be experienced following amputation, clinicians should also be aware of the pain that may be caused by co-existing pathology:
Prosthetic pain is also a concern and may be caused by:
Treatments[edit | edit source]A large variety of medical/surgical and non-medical methods exist for the treatment of post-amputation pain:
Read more about Pain management in amputees Read about Phantom Limb Pain Read about Mirror Therapy and Graded Motor Imagery Muscle Weakness, Contractures and Joint Instability[edit | edit source]After amputation, it is not uncommon for patients to experience pain, muscle weakness or instability in structures not directly associated with the amputation. These compensatory structures are the muscles and joints that are required to perform additional functions post amputation, often resulting in stiffness, spasm or pain. The effects of bed rest and reduced mobility are also well documented. Deconditioning results in diminished muscle mass, sarcomere shortening, reduced muscle strength and changes in cartilaginous structures [13]. It is, therefore, crucial, that amputee patients undertake functional rehabilitation and personalised exercise programmes from as early as day 1 post surgery. Hip flexion contractures and knee flexion contractures are common complications post amputation and can impact significantly on prosthetic rehabilitation. ROM exercises should be incorporated to avoid contractures, as well as prone lying to prevent hip flexion contractures, a sandbag could be placed next to the residuum to prevent a hip abduction contracture. A sandbag could also be placed on the lower part of a transtibial residuum when the patient is prone, to prevent hip flexion contractures.[14]. Physiotherapy regimes should consist of the following elements:
Autonomic Dysfunction[edit | edit source]Complex regional pain syndromes (CRPS) are neuropathic pain disorders developing as a disproportionate consequence of trauma affecting the limbs [17]. Symptoms include distal pain, allodynia and autonomic and motor dysfunction. The residual limb can appear hot, swollen and trophic due to altered control of the sympathetic nervous system. Due to the lack of understanding about the pathophysiological abnormalities underlying CRPS, treatment should be multi-disciplinary and comprise of neurologists, physiotherapists and psychologists to name but a few. Anti-depressants are proven to be beneficial in reducing neuropathic pain [18] alongside nerve blocks, TENS, graded exercise and mobilisation. Osseointegration Specific Complications in Trans Femoral Patients[edit | edit source]Rare major complications
Common minor complications:
Resources[edit | edit source]Musculoskeletal Complications in Amputees: Their Prevention and Management References[edit | edit source]
What are the complications of immobility?Immobility is independently associated with the development of a series of complications, including pressure ulcer [1], deep vein thrombosis (DVT) [2], pneumonia [3], and urinary tract infection (UTI) [4].
What are complications of bed recumbency?Problems Due to Bed Rest. Blood clots. A leg injury, leg surgery, or bed rest may prevent people from using their legs. ... . Constipation. ... . Depression. ... . Pressure sores. ... . Weak bones. ... . Weak muscles and stiff joints. ... . Prevention of Problems Due to Bed Rest.. Which of the following is a complication of bed rest?Information. How does immobility affect the musculoskeletal system?Prolonged bed rest and immobilization inevitably lead to complications. Such complications are much easier to prevent than to treat. Musculoskeletal complications include loss of muscle strength and endurance, contractures and soft tissue changes, disuse osteoporosis, and degenerative joint disease.
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