Lower extremity amputation at any anatomic level is a life-altering event for patients. Accordingly, the panelists discuss multidisciplinary post-op referrals/protocols and patient education with an outlook toward ulcer remission, further limb salvage, quality of life and the benefits of support groups.
Once a patient heals after a lower extremity amputation of any level, what services or referrals do you often institute to help him or her return to daily activities?
All of the panelists agree that a referral to an orthotics and prosthetics professional is a crucial post-amputation intervention. Along with custom diabetic shoes and custom inserts, the panelists cite toe fillers, braces, ankle-foot orthoses, Charcot restraint orthotic walker (CROW) boots and prosthetic limbs as possible modalities, depending on the case.
“Anything more significant or proximal than a single toe amputation may benefit from an orthotist consultation visit,” says Kazu Suzuki, DPM, CWS.
Ashley Miller, DPM, DABPM shares that her team commonly refers patients to physical therapy after they have had a transmetatarsal amputation (TMA).
“We like to try physical therapy to avoid further surgery for biomechanical changes associated with the TMA,” explains Dr. Miller.
Dr. Suzuki elaborates on the role of physical therapy post-amputation.
“Unless it is just a simple toe amputation, I almost always refer my post-amputation patients to physical therapy,” maintains Dr. Suzuki. “Since many of our patients have gait disturbance and stability issues, I believe it is helpful to have a physical therapist examine their gait and work with them, even just for a single visit or, ideally, over several sessions to strengthen and correct their gait. Many of these patients have baseline neuropathy and deconditioning that come from post-op non- or partial-weightbearing status that put them at high risk for ground level fall injuries.”
Jeffrey Ross, DPM, MD, FACFAS adds occupational therapy to the post-amputation treatment pathway. He prefers that occupational therapy is concurrent with physical therapy. Dr. Ross says both should occur while the patient is still in the hospital and prior to the prosthetic process of donning a shrinker with subsequent casting, test fitting and delivery of a below-knee or above-knee prosthesis.
For those patients with partial ray, transmetatarsal or Chopart amputation, Dr. Ross says the evaluation can take place in the hospital and fitting can occur at the brace and/or prosthetic limb lab once the wound sites resolve.
“Multidisciplinary therapy is crucial for these patients prior to receiving their new prosthetic device in order to increase upper body and core strength,” points out Dr. Ross. “It is important to know how to use the prosthesis correctly and to perform gait training. The use of the MatScan pressure mat (Tekscan) and gait analysis, 3-D scanning, plaster casting, and/or crush foam to create accommodative insoles and orthotics is also beneficial.”
Dr. Suzuki asserts that revisiting and renewing patient education, even at basic levels, is key during this time. He says he still witnesses his patients using shoes with worn soles for several years at a time. This educational outreach can include an emphasis on routine foot hygiene, proper socks and properly sized and fit shoe gear.
“For many of our post-amputation patients, I recommend HOKA One One® running and walking shoes as I find that they have maximal cushioning with reasonable prices,” asserts Dr. Suzuki.
What, if any, other supportive services do you consider or recommend for these patients in order to address issues associated with the amputation and improve overall quality of life?
Each panelist highlights the importance of introducing patients and even family members to available support groups after amputation. In addition to emotional support, the panelists share that these groups may also provide patients with information on social and psychological services, financial issues, medical providers, equipment and other vital resource information.
Dr. Miller says that her county facility does not have any amputation support groups but the Veterans Administration system in her area does. She says these groups allow post-amputation patients or those about to have an amputation to share experiences.
“This group discussion can really help patients understand that they are not alone and have others to reach out to for issues and concerns,” adds Dr. Miller.
When such a group is not available, Dr. Miller finds it important to engage family members in the conversation about the treatment plan as well as what the future may look like with a pedal and/or limb amputation. Dr. Suzuki says he also encourages family and friends to help patients after amputation with personal care activities and household chores as they are usually immobilized to some extent.
Additionally, Dr. Ross feels that either prior to their surgery or after the amputation, patients may benefit from working with a psychiatrist or psychologist (at least weekly) to help with potential depression and grief. He finds that addressing mental health is especially important to prevent severe depression in this population.
“My support advocate at my brace and limb lab had a left below-knee amputation in 2015,” shares Dr. Ross. “She had known her leg for 45 years so the amputation was a huge loss as if she had lost a loved one. With the support of a psychiatrist and psychologist, she was able to go through a grieving period and still move forward with her new way of life. Part of her self-care was addressing her mental health, which she believes is a huge part of why she currently has a great quality of life.”
What other management strategies do you use for patients to prolong ulcer remission after amputation?
Dr. Suzuki advocates for monitoring patients at high risk for limb loss at a minimum of every two months. He determines risk stratification based on disease history, blood glucose control, activity level, level of neuropathy, blood perfusion status, comorbidities, occupation and many other factors.
“For example, I see many patients with wounds at once-a-week intervals,” shares Dr. Suzuki. “Once the wound heals, I may see the highest risk patients every two weeks and then I may increase the interval to four, six or eight weeks if they are problem-free during that time.”
Dr. Miller shares that her ulcer remission protocol involves continued follow-up every three to four months for at-risk patients. However, her health system has an “expected practices” system set up for local primary care providers that outlines a map of care for patients with diabetes.
“This map gives guidance to primary care on how to manage the diabetic foot and when to consult podiatry for further management,” elaborates Dr. Miller. “We also use video visits for our patients who are high risk for re-ulceration but do not necessarily need an in-person appointment.”
Dr. Ross agrees that close physician follow-up is important but adds that continued prosthetic team management also contributes to long-term success. He goes on to explain that the prosthetist will check skin quality, alignment of the device and make sure the patient has necessary supplies.
Overall, Dr. Ross emphasizes that a multidisciplinary approach, ideally involving the creation of a center of excellence for limb preservation, is essential. He points out that this team should include a podiatrist, interventional vascular surgeon, endocrinologist, cardiologist, infectious disease specialist, orthopedist, psychiatrist/psychologist, physical medicine specialist and nutritionist as well as physical and occupational therapists.
Maintenance of adequate blood flow to the extremity should be addressed by vascular surveillance every six months, according to Dr. Ross. He says this surveillance might include ankle-brachial indices, arterial dopplers, indocyanine green angiography (SPY Elite, Stryker), and/or Snapshot NIR (Kent Imaging) that measures hemoglobin.
“Advances in technology can be an integral part of post-op amputation care,” says Dr. Ross.
Dr. Ross adds that other technologies that benefit a post-amputation care pathway might include computerized F-scan gait and pressure analysis. This might contribute to enhanced evaluation and intervention with accommodations to insoles/orthotics, or even surgery for equinus or high degrees of forefoot varus that lead to recurrent forefoot ulceration.
“After amputation, the foot changes and is subject to pressure and re-injury,” says Dr. Ross. “Prevention is essential.”
Dr. Miller is a member of the diabetic limb preservation staff in the Department of Surgery at Harbor-UCLA Medical Center in Torrance, Calif. She is a Diplomate of the American Board of Podiatric Medicine.
Dr. Ross is an Associate Professor of Surgery in the Division of Vascular Surgery and Endovascular Therapy at Baylor College of Medicine in Houston, Texas. He is a Fellow of the American College of Foot and Ankle Surgeons, the American Academy of Podiatric Sports Medicine, the American College of Sports Medicine, and the American Professional Wound Care Association.
Dr. Suzuki is the Medical Director of the Apex Wound Care Clinic in Los Angeles. He is also a member of the attending staff of Cedars-Sinai Medical Center in Los Angeles. He can be reached at Kazu.Suzuki@ cshs.org.