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Ambulation on Postoperative Day 1 after Bilateral Transtibial Amputations: A Case Report and Literature Review

Faucher, Lee D. MD; Shurr, Donald G. CPO, PT

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JPO Journal of Prosthetics and Orthotics: April 2005 - Volume 17 - Issue 2 - p 47-49
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The loss of a limb is a potentially devastating event that can lead to severe psychological, physical, and vocational limitations. More than 80% of major lower-extremity amputations are attributable to peripheral vascular disease.1 Trauma accounts for about 16 percent, with the number declining during the last several years.2 The incidence of trauma-related bilateral lower extremity amputations is 0.5 per million persons in the United States.2

CASE REPORT

On a winter evening during which the temperature dropped to −1°F,3 a 24-year-old man was involved in a single-vehicle rollover crash. After 36 hours of subfreezing temperatures, during which he remained conscious with his feet submerged in water, he was rescued and admitted to our Level 1 trauma center in stable condition with a core body temperature of 94°F. Both of his lower extremities were insensate and had no motor activity. He was awake and alert. He reported pain associated with a left auricle laceration. External warming devices quickly returned his core temperature to normal. During the next several days, minimal motor function returned below his knees, but he never regained sensation of his feet.

The patient was kept informed that double amputation of his lower extremities was a possibility. During wound care 18 days after the trauma, purulent drainage was noted coming from under the previously dry eschar. The patient had no fever or signs of sepsis. His white blood cell count, previously 10,400/cu mm, increased to 15,300/cu mm that day. He was taken to the operating room for excision of the eschar and drainage of the abscess. No viable tissue remained in the foot or ankle. The tissue of the lower leg was viable and healthy proximal to the level of the midtibia. The patient returned to the operating room 2 days later for transtibial amputations of both lower extremities.

The day before the definitive amputations was used for patient and family education. The surgeon was able to explain the procedure and the postoperative plan. Members of the physical therapy department along with a prosthetist were able to explain the entire process of rehabilitation. The patient would be placed in rigid dressings and pylons in the operating room and ambulation would begin immediately. The advantages of this approach, including decreased length of hospital stay, earlier return to work, and earlier placement in definitive prostheses, were discussed with both the patient and his parents, and all questions were carefully answered to assure the complete cooperation of the patient and his family. Table 1 lists the functional goals to be achieved before discharge.

T1-4
Table 1:
Discharge functional goals

Both tibias were cut five inches from the tibial tuberosity and the wound was covered with a long posterior flap and closed with deep absorbable sutures and skin staples. A light dressing covered the surgical wound, followed by a compressive residual limb stocking. In the operating room, the patient was fit with two rigid dressings with pylons and feet (Figure 1).

F1-4
Figure 1.:
Postoperative photograph showing casts and pylons in place. The area covering the patella was removed to minimize pressure.

The patient was transferred to a tilt table and rotated to a 65° angle for 25 minutes without complications on the morning of postoperative day 1. Care was taken by the physical therapist to reduce as much as possible the shear forces on the anterior of the patient’s residual limbs during the process of rising and sitting because both knees were casted in the extended position and were unable to flex. The afternoon of postoperative day 1, the patient was rotated to 90° with full weightbearing and took a step away from the tilt table with a two-person assist. He then used a walker to walk 10 feet. His activity continued to increase as he began to get himself out of bed by sitting on the edge of the bed, placing a walker in front of him, and pressing with his upper extremities to a standing position. He then would walk with a walker without assist. Distance of walking was limited to 20 to 30 feet in the first few days to allow the patient to develop a tolerance to walking and standing. In later days, the distances were increased, and eventually stairs were incorporated. When he was discharged from the hospital on postoperative day 10, he was able to get himself out of bed and perform transfers. He also was able to climb stairs using only the handrails for support. He understood fall safety and was able to ambulate 100 feet with a walker. His in-hospital therapy program included daily lower extremity strength and conditioning, quadriceps and gluteal strengthening, and straight leg raises. Table 2 lists the functional activities by postoperative day.

T2-4
Table 2:
Functional activities by postoperative days (POD) 1–10

His casts were first changed on postoperative day 14, and the staples were removed. After the residual limbs were inspected, they were again placed in two new rigid dressings, and the patient returned home. The same practitioner evaluated the patient and changed the casts at 4 weeks and 6 weeks after surgery. The wounds continued to heal without incident, and the first preparatory sockets were fitted 6.5 weeks after surgery. The wounds were completely healed without any clinical signs of vascular compromise. The tissue had excellent capillary refill and no tissue breakdown.

DISCUSSION

Although Wilson4 reported positive results of early weightbearing in traumatic amputations in 1922, it was Berlemont5 in 1961, and again in 1966,6 who reported on this treatment and sparked the interest of the prosthetics profession worldwide. Weiss7 in Poland, and Burgess and Zettl8 in Seattle began using the technique with good results on veterans from the early Vietnam era.

The technique applied in this case followed that of Burgess and Zettl,8 resulting in minimal pain for the patient during the first 2 weeks of standing and wound healing without complications.

Few controlled studies exist that demonstrate statistical significance in clinical outcome by type of postoperative dressing. Nearly all studied unilateral subjects with a variety of etiologies, often vascular in origin. Baker et al.9 reported significantly shorter rehabilitation time using rigid dressings compared with soft dressings. Similarly, Mueller10 found statistically significant reduction in limb volume. Schon et al.11 found that by using prefabricated pneumatic prostheses, fewer postoperative complications occurred and fewer limb revisions were needed.

This case report highlights the utility of accelerated rehabilitation with rigid postoperative dressings in the treatment of a young traumatic bilateral amputee to minimize the time to weightbearing and walking, and the fitting of the preparatory prostheses. This method of treatment should be applied only to patients without peripheral vascular disease or medical conditions that can complicate wound healing. Our patient was in excellent physical condition before his accident. This was highly beneficial because he was able to use his upper body strength to assist ambulation. A patient without adequate upper body strength to support his or her own body weight would not be able to advance as quickly. No problems were reported, and the patient is now in his definitive prostheses. Although the literature supports an ever-decreasing number of cases of unilateral traumatic transtibial amputations done on young, active people, trauma teams should remain cognizant of this useful option as the need arises.

REFERENCES

1. Feinglass J, Brown JL, LoSasso A, et al. Rates of lower-extremity amputation and arterial reconstruction in the United States, 1979 to 1996. Am J Public Health 1999;89:1222–1227.
2. Dillingham TR, Pezzin LE, MacKenzie EJ. Limb amputation and limb deficiency: epidemiology and recent trends in the United States. South Med J 2002;95:875–883.
3. State Climatologist: Iowa Department of Agriculture & Land Stewardship; 2004.
4. Wilson PD. Early weight-bearing in the treatment of amputations of the lower limbs. J Bone Joint Surg Am 1922;4A:224–247.
5. Berlemont M. Norte experience de l’appareillage precocedes amputes des membres inferieurs aux Etablissements Helio-marins de Berck. Ann Med Physique 1961;4:213–218.
6. Berlemont M, Weber R, Willot JP. Ten years experience with immediate application of prosthetic devices to amputees of the lower extremities on the operating table. Prosthet Int 1969;3:8–18.
7. Weiss M. Neurological implications of fitting artificial limbs immediately after amputation surgery. Report of the 5th Workshop Panel on Lower Extremity Prosthetic Fitting. Subcommittee on Design and Development. National Academy of Sciences, Crystal Mountain, WA, February 6–9, 1966.
8. Burgess EM, Zettl JH. Amputations below the knee. Artif Limbs 1969;13(1):1–12.
9. Baker WH, Barnes RW, Shurr DG. The healing of below-knee amputations: a comparison of soft and plaster dressing. Am J Surg 1977;133:716–718.
10. Mueller MJ. Comparison of removable rigid dressings and elastic bandages in preprosthetic management of patients with below-knee amputations. Phys Ther 1982;62:1438–1441.
11. Schon LC, Short KW, Soupiou O, et al. Benefits of early prosthetic management of transtibial amputees: a prospective clinical study of a prefabricated prosthesis. Foot Ankle Int 2002;23:509–514.
Keywords:

bilateral; early ambulation; frostbite; prosthesis; transtibial amputation

© 2005 American Academy of Orthotists & Prosthetists