special subjects
Preparing for a Limb Prosthesis
Postoperative and Preprosthetic Considerations
Postoperative management goals are to Protect the residual limb from accidental trauma (eg, bumping, falls) Control edema Promote healing Maintain strength, cardiovascular endurance, and joint range of motion There are many dressing options to protect the residual limb and control edema. Effective management of edema increases circulation, promotes healing, and reduces severity of postoperative pain and Phantom pain . A physical therapist will work with the patient before and after hospital discharge as needed based on the patient's abilities and specific amputation. Training may include standing balance, walking in parallel bars, use of a walker, crutches, and/or wheelchair, and self-care skills including transfers and personal hygiene. The prosthetist will see the patient weekly to monitor progress and residual-limb readiness for fitting a preparatory prosthesis, which is done when residual-limb fluid volume is reasonably stable. When the residual limb has healed and fluid volume has reached an initial level of stability—usually 6 to 10 weeks postoperatively, but longer if there are complications—a preparatory prosthesis can be fitted. A preparatory prosthesis is a temporary prosthesis that allows progressive weight-bearing and switching of components to match patients' changing functional requirements as they become accustomed to walking and doing other activities. The socket of the preparatory prosthesis may need to be refit several times during this period. In addition to improving mobility and independence, advantages of early prosthesis fitting include achieving better acceptance of the amputation, restoring body image, reducing phantom pain, increasing proprioception and phantom sensation, and hastening maturation of the residual limb. The residual limb of adults continues to undergo considerable volume and shape change for 12 to 18 months after amputation. At this time the preparatory prosthesis can be exchanged for a permanent or definitive prosthesis, which often uses the same joint and appendage components that were identified as optimal during the preparatory phase. However, even after a residual limb is considered mature (> 18 months postamputation), residual-limb fluid volume will continue to fluctuate daily and long-term. The magnitude of change varies among individuals and can be problematic. The patient initially learns how to function with a prosthesis during the Fitting the Prosthesis . The process involves several appointments to achieve acceptable levels of comfort and stability. For patients with an upper extremity prosthesis, once comfort and stability are achieved, the prosthetist works to provide maximum functional capacity with appropriate spatial positioning of joints and appendages. An occupational therapist then works with the patient to optimize function for the patient’s specific daily activities. For patients with a lower extremity prosthesis, once residual limb comfort and stability are achieved, a prosthetic hip, knee, ankle, and/or foot is introduced to achieve balance and posture. The patient initially begins ambulation within parallel bars. The prosthetist ensures that sufficient biomechanical efficiency is achieved before the patient is seen by the physical therapist for gait training. As the patient learns to ambulate effectively, the prosthetist will modify the socket to compensate for morphologic changes in tissues and in biomechanical alignment of joints and appendages. In addition, as the patient acclimates and is able to ambulate more aggressively, the prosthetic hip, knee, ankle, and/or foot may require changes to provide optimal, efficient ambulation and function. Counseling or psychotherapy may help when patients have prolonged difficulty adjusting to the loss of their limb and to prosthetic use. 