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Prosthetic Treatment

Introduction

This information pack is provided to help people who will have / have undergone an amputation of the lower limb. Its purpose is to try and explain what will happen and to answer the questions that you may have at this time.

If you have any questions that are not covered in this guide please write them down and ask an appropriate person e.g. doctor, surgeon, nurse or contact us at KOE.

Thank you. We wish you a speedy recovery

The team at KOE

 

Reason for amputation

There are several reasons why an amputation is required; your doctor will explain the reason(s) why you need an amputation. Some of these reasons are:

  • Due to disease of the blood vessels where the arteries become narrowed, thus limiting the blood supply to the legs and feet.
  • Circulation problems or severe infection due to complications of diabetes.
  • As a result of an accident or injury.
  • Tumors.
  • Problems with a baby's development before birth.

In many cases, prior to amputation, the limb may have caused serious problems of infection and pain, and been a threat to life.

 

Levels of amputation

There are several levels of amputation, which a surgeon can perform. The level of amputation will depend of the state of your circulation and surrounding tissues. The most common levels are;

Treatment

  • hip disarticulation (through the hip joint),
  • transfemoral (above the knee),
  • Knee disarticulation (through the knee joint)
  • transtibial (below the knee).

 

What to expect after your amputation

Following the operation you may find that you have a tube in your arm, which allows fluid to feed into your body to replace any lost during the operation. This can be helpful for the first few hours after surgery when you may not be drinking.

Your residual limb (the part that is left) may be heavily padded and bandaged giving the limb a bulky appearance. There may be a small drainage tube coming from the wound site, which allows the excess fluid to be removed. The wound is usually held together with stitches. There may be one long continuous stitch or many small stitches or clips.

The stitches or clips are removed about three weeks after the operation but the time scale can vary depending upon the condition of the wound. Sometimes healing may be delayed due to certain medical conditions.

 

Pain control

Following all operations, people will usually experience pain whilst the wound is healing. After an amputation, pain will usually occur around the wound areas. It is important to make the doctors aware of any pain you are felling so that they can provide you with adequate pain control. If the pain and discomfort is controlled, you will be able to start early exercises move around the bed and transfer from bed to chair and back. This is a vital part of your rehabilitation. As the wound heals the pain generally disappears.

 

Phantom limb sensations

What are they?

Many people who lose a limb feel that it is still there. This is quite normal. It is called phantom limb. Usually it feels the same length and weight as the original leg. You may feel these phantom sensations in the whole leg or just part of it ie; one toe or calf. You may feel that the leg is in an odd position ie; such as twisted or in tight shoe.

The phantom sensations in you leg feel real and therefore it is very easy to think that you leg is still there and try to stand on it. It is therefore important that you concentrate when standing and transferring or you may fall. This is especially true if you have just woken up.

 

What causes phantom sensations?

At first, your brain isn't used to your leg not being there. The nerves that went into your foot still send messages to the brain even though they have been cut. Your brain remembers that for all who can those years these nerves went down your leg to your toes and so, when it gets these messages it thinks your leg, or part of it is still there.

 

Phantom limb pain

In some people the phantom feeling can be painful. The pain can be a tingling, burning, itching or cramping sensation or even a more painful sharp or shooting pain. The cut nerves in the residual part of the limb can be sensitive to various stimulation including; swelling, pressure from a prosthesis, muscle spasms in the leg, knocking or bumping the residual limb, temperature, the weather, stress or sometimes they come on for no apparent reason at all.

 

What can be done to relieve them if they are painful?

They usually lessen with time, or you learn to ignore them. Keep a diary to see if you can see a pattern to the pain or see what brings it on. Like any pain, it helps if you do something to keep your mind off it. Relaxation, massage or a support sock can help.

There are specific drugs and treatments that can help phantom pain if necessary.

Transcutaneaous Electrical Nerve Stimulation (TENS) machines provide a different sensation for your brain and therefore disguise the phantom pain. Discuss these ideas with your doctor or ask your therapist to offer you advice.

 

Reaction to amputation

People react differently to the loss of a limb. If the history leading up to the amputation was a long period of pain, having the amputation may give a sense of relief that this is all over. However, for many people having an amputation is very difficult to come to terms with and they may feel shocked, sad and even angry.

A period of bereavement is usually experienced and this is the normal reaction to loss, which may be experienced in many ways. It is normal to feel varied emotions after lOSing a limb as adjusting to changes can be challenging. Talking about your feelings will be helpful, and support from staff as well as family and friends is important.

A counseling service is available to enable you to talk about any difficulties you may be having. The counselor may also help support any of your family / carers.

 

Early Rehabilitation after Your Amputation

You will usually meet a physiotherapist following your operation, who will teach you breathing exercises. These help any chest problems that may arise following the anesthetic. Gentle exercises, which you can do whilst in bed, may also be taught.

When you well enough, either the nursing staff or physiotherapist will help you to get out of bed. They will assess your capabilities to see how much help you will need; this may vary from needing a hoist/ the help of two people / or managing by yourself.

You will be shown exercises to keep the strength in your muscles and to prevent joints from becoming stiff -especially the hips and knees.

It IS important to keep doing these exercises whilst in hospital and when you are discharged home.

 

Care of your residual limb

If you have had an amputation at the below knee level, it is important when sitting in a chair or wheelchair to avoid letting your residual limb hand over the edge of the chair unsupported. If the limb is allowed to hand down like this, it causes increase swelling in the limb and stiffness in the knee. This swelling and stiffness causes more pain and delays the healing process. You may have your stump bandaged or be supplied with a special compression sock for you to wear which will help to control the swelling.

Whilst your wound is healing, the nursing staff in the hospital, or possibly the nurse who comes to your home, will take care of your residual limb. When this has healed and the stitches have been removed you can then look after it yourself.

Gentle handling of your residual limb when washing and drying will help it to become less sensitive. You should wash your residual limb morning and night with unscented soap and warm water. Gently dry it and do not use talcum powder or creams unless advised to do so by a health professional.

It is recommended that you do not hop either with or without a frame or other walking aids. If you fall and damage your residual limb this could delay your rehabilitation assessment and cause you more pain. Using a wheelchair is the safer option for mobility at this stage.

 

Residual limb Massage

Massage can be soothing if your residual Iimb is sore, painful or hypersensitive and should be performed gently. Sometimes light ‘tapping' can help too. It can help to control and lessen phantom pains and sensations Massage can also stimulate the circulation to aid healing and reduce swelling. If you have thickened and adherent (stuck down) scar tissue, massage can help the skin to become more supple. This will reduce any problems that may occur inside the socket.

There is a special way of massaging the residual Iimb that may help to reduce sensitivity, improve circulation and prevent scar problems. You put one hand underneath the residual limb and the other on top and squeeze gently but firmly. Whilst still squeezing you move one hand forwards and the other backwards. This moves the muscle not the skin. A member of the rehabilitation team will advise you on how and when to commence the massage.


Further Rehabilitation:

Primary appointment at the prosthetic clinic

At the first available opportunity you will be given an appointment to see us at the prosthetic clinic. At this appointment we will assess the way in which we can maximize your rehabilitation. This can vary from wheelchair independence to using prosthesis. Many factors need to be considered: Your state of health (including heart and chest problems, neurological problems and arthritis) your aims, rehabilitation progress and the benefits and difficulties of using an artificial limb.

Not everyone who has an amputation will be considered suitable or goes on to use an artificial limb. Some people may find that walking with an artificial limb is very tiring and they choose to get about using the wheelchair instead. You should never compare yourself to anyone else; everyone is an individual and gets treated as such. If you wish, someone may accompany you to this appointment. We will want to learn a little about your lifestyle, housing, hobbies and work as this can influence the type of prosthesis suitable for you.

We will also discuss with you:

  • The choice of prosthesis
  • The procedure and plan for making your first prosthesis

 

Your first Artificial Limb

Casting and Measuring:

There are different types of artificial limb for each level of amputation. We can sometimes show you examples of different types so that you can get an idea of what it will be like. Before your artificial limb can be made, the prosthetist will take some a plaster cast. Casting involves wrapping wet plaster bandages around your stump to create a mould. This is used to make a socket into which your residual limb (stump) will fit. Measurements of your residual limb and other leg/arm will also be taken.

 

Fitting

The next appointment will be for the fitting of your artificial limb with a diagnostic socket. The prosthetist will ask you to try your artificial limb on to check the fit and comfort. Some adjustments may be required. As the artificial limb has not been finished it can look quite strange at this stage. When both you and prosthetist are satisfied that the socket is comfortable, the artificial limb will be returned to the workshop so that it can be made ready for you take home.

After your amputation, your stump is likely to be quite swollen, so do not be disappointed if your first artificial limb is larger in size than your other limb. The next socket is likely to be smaller as your stump heals and the swelling reduces.

You will be given help to put it on and be asked to walk between parallel bars to check it is comfortable. The prosthetist will be able to answer any questions you may have regarding your new artificial limb

 

Reviews

You may return to clinic several times for us to check your prosthesis for fit and alignment. Adjustments to alignment and socket fit are common at this stage as your residual limb reduces and you become more proficient/confident at using it.

 

Definitive Socket

When all is well, a Definitive socket will be made and fitted to your prosthesis. You will have to attend for a final fitting. Your prosthesis will then be finished.

Future appointments relating to ongoing care will be discussed at this time.

 

Wearing Your Prosthesis

Build up the time wearing the prosthesis gradually. It is recommended that you start with frequent, short spells at first, increasing the length of time as you body adjusts, for example;

Week one -Half an hour to an hour morning, afternoon and evening. If this is too much for you reduce to two sessions

You may find that you develop mild aches and pains in other parts of your leg, back or hips; these are quite normal and are a sign that your body is adjusting to the limb. You may also feel more tired than usual.

Weeks two I three - One to two hours, morning, afternoon and evening.

Weeks four to six - Two to three hours, morning afternoon and evening.

At all times listen to your body -it is very important not to 'over-do it'. Always stop before you have to and don't be disappointed with your progress. Every person is an individual and should adapt I progress at their own rate and within their capabilities.

Depending on your speed of progress you should work towards wearing the limb all day. However, sometimes even a very short break of 10 minutes can make difference in the early stages. It will feel very strange at first, a bit like a 'spare part' but as you become accustomed to it, it will begin to feel more a part of you.

If you develop a rash at any time, contact your prosthetist. Skin irritation may be caused or made worse by limb wearing. You may be advised to stop using the prosthesis for a day or two or, to see your doctor.

It is quite normal to get reddish marks on your skin at the edges of the socket -these should not cause much irritation but the skin will gradually get used to them. They are no different than strap marks on your feet from wearing sandals.

The socket should not cause the skin to chafe or become sore. It you find this happening, arrange to see your prosthetist. Do NOT wait for your next appointment.

Your stump is expected to reduce in size over the first few months or more. If your socket starts to become lose contact your prosthetist who will arrange an appointment for you to have the socket adjusted or advise on the use of extra socks.

 

Looking After Yourself

Care of your residual limb

It is best to look after your residual limb (amputated leg) just as before, when it were your whole leg.

 

Diabetes

If you have diabetes, it is very important to keep your blood sugar levels well controlled;

  • To allow healing to occur and reduce the risk of infection after your amputation and
  • To prevent further complications

Your physiotherapy regime may reduce your sugar levels and your diet and medication may need to be changed accordingly. If you have increased your walking as a result of having a new leg prosthesis, you should monitor yourself closely. You must let the clinicians know if you have diabetes or if you feel unwell.

 

Hygiene

Wearing a prosthesis may result in perspiration which will be trapped as air cannot circulate.

  • Wash your residual limb every morning and evening with a mild soap and water.
  • Dry your leg thoroughly and do not use any medicated creams or oils unless advised to do so by your doctor, nurse therapist of prosthetist.
  • Clean your socket or liner daily and use clean stump socks next to your skin.
  • Massage moisturiser into the skin before bed. Be sparing. Avoid heavily perfumed or greasy moisturisers
  • Check your residual limb daily for any signs of broken skin, redness or blistering. Use a mirror if necessary. DO this more frequently if it is sore.
  • Keep cuts and blisters clean.
  • If any skin problems persist, seek advice from your doctor .If you have been given a 'shrinker' sock or light elastic bandage to wear, continue to wear it when you are not wearing your artificial limb to prevent swelling and shape change of the residual limb.

 

Sweating

Excessive sweating is not unusual but can cause problems for your skin and your socket suspension, especially in hot climates. Antiperspirants can be applied daily to reduce sweating.

Examples recommended are;

  • Odaban
  • Dryclor
  • Mitchum
  • Anhydrol Forte

 

Rashes

Skin irritations are common. The following can be applied to clean skin:

  • E45 -in very thin quantities as it can clog the pores and irritate .
  • Diprobase
  • Calendular
  • Antifungal-only when prescribed

 

Care of your remaining limb

Your remaining limb is doing more than half the work on a daily basis. It is important to look after the condition of your skin and not to overstrain the joints, muscles and ligaments.

  • Wash your foot daily and dry it carefully
  • Check your foot for swelling, changes in colour, pain, sores and breaks .If you have any skin problems with your remaining foot see your doctor
  • Take care when choosing shoes will help foot control. A rubber sole will aid shock absorption and provide improved grip to prevent slipping
  • Do not wear socks with tight elastic tops.
  • Do not wear socks with thick seams if you have reduced sensation.
  • Wear cotton socks that better absorb sweat and remember to change them every day.
  • Do not be tempted to hop around. Remember your remaining leg has to do extra work already. This can bring on arthritis in later life .
  • If you are experiencing foot pain, seek advice from your doctor or therapist

 

Avoiding weight gain

Maintaining your weight at a sensible level is essential following an amputation. Excessive weight gain could affect your general health, prevent your artificial limb fitting and means you will be less active.

Weight gain is not unusual following an amputation. To begin with it may result from an improvement in health following a long illness. In the long-term lower activity levels may cause weight to increase.

Some guidelines on the foods to choose in order to stay as slim and healthy as possible.

  • Eat regular meals
  • Eat plenty of foods rich in starch and fibre
  • Don't eat too much fat
  • Eat less sugar and sugary foods and drinks
  • If you drink alcohol, limit the amount

 

Smoking

Smoking compromises your skin condition, your lung capacity and your blood vessels to vital organs such as your heart and brain. When you wear an artificial limb it is important for you to be as healthy as possible so that you can compensate for the missing limb. Smoking can delay the healing of any wounds and it may cause any circulatory disease to deteriorate in your leg.

Therefore, it is very important to STOP SMOKING to prevent this.

Your doctor may be able to help you quit with the appropriate medication.

 

Exercise

Participating in exercise or sport will help you to remain fit, strong and healthy. This will help you to compensate better for any disability and help you to remain active and independent.