Getting Started

 
 
Post-Op Liners

If you have had an amputation or are facing amputation please read the content provided to prepare you for the next steps. At Deist & Associates we are passionate about staying by the patient’s side through the entire process: from amputation through to being fit with your permanent prosthetic.

It is very important for a new amputee to get moving as soon as possible after an amputation. Trans-tibial amputees (leg amputations below the knee) are fitted with an Post-Op Liners for the first six weeks after the operation. Post-Op Liners can be fitted in the operating theatre immediately after surgery and stays in place until the first dressing change, which can be up to 24 hours. It is removed at regular intervals so that the wound can be inspected and dressings changed. After 24 to 48 hours the Post-Op Liners can be removed at night for comfort.

Post-Op Liners can also be fitted at a later date after surgery, in which case a gradual wearing schedule is recommended. Start off with just three hours on the first day and increase the time by between one and two hours every day, depending on the patient’s comfort zone. The Knee-stabilizer can be removed in both cases to enable the patient’s knee to flex.

This temporary prosthesis consists of a universally sized adjustable outer shell lined with a number of inflatable air cells, which enable the Post-Op Liners to accommodate a wide range of sizes throughout the process of rehabilitation. These help with the circulation and control any swelling, encouraging healing.

Post-Op Liners is centred and adjusted with its buckles and air cells, ensuring a balanced position above the pylon. When the patient is lying down or seated, the limb should be extended at the knee or elevated with a pillow placed beneath the prosthetic foot or distal socket.

After six weeks of using the Post-Op Liners, we start fitting you with your first prosthesis proper. It will be snug and comfortable for six to twelve months. After this time you will notice that the stump has shrunk, and so the socked part of your prosthesis will have to be replaced with a new snug fitting one.

Your First Year

What You Might Expect During the First 12 Months as a Lower-Limb Amputee

As a recent amputee, if you feel clueless about what to expect during your first year as an amputee, you’re not alone. While there are no set guidelines that will fit every amputee’s individual situation, there are some generalities that may apply. One certainty is that you will see your prosthetist many times during your first year as an amputee, possibly as many as 15 to 20 times, if not more. For this reason, you should do everything in your power to find a prosthetist that you are comfortable with.

Following your amputation, you and your residual limb will start your respective psychological and physical healing processes. Depending on how fast your limb heals, you should expect to have your stitches/staples removed within 3 to 4 weeks of your surgery. You should start pre-prosthetic physical therapy soon after your amputation; this includes working on your upper body strength and your lower limbs to maintain good range of motion in your hips and knees and strength in your leg muscles. You should also start desensitising your residual limb by rubbing it and manually moving your tissue around with your hands to loosen any scar tissue that might develop inside your limb. You will also meet your prosthetist multiple times, first for a consultation/evaluation and then to be fitted with a “stump shrinker” (an elastic stocking, or Post Op Silicone Liners) that will start shaping your residual limb for initial prosthetic fitting.

Once your incision has completely healed, your stitches have been removed and your doctor has provided a prescription for an interim prosthesis, you will meet with your prosthetist to be measured and cast. Depending on how your prosthetist works, he or she will either cast your residual limb or do a total contact casting method with a fibre glass resin socket directly onto your residual limb.

Once your prosthetist has a positive model of your limb, it will be used to create a diagnostic (check or test) socket for test fitting purposes. This socket will be connected to a knee (for Trans Femoral amputees) or just a pylon (for Trans Tibial amputees), which in both cases will then be connected to a prosthetic foot. A test fitting with your prosthetist might be completed in one visit or it could take multiple visits. Once a diagnostic socket is deemed to fit “comfortably,” your preparatory Interim socket will be fabricated and connected to your other prosthetic componentry, resulting in your first prosthesis. Adjustments to this prosthesis may be required during the first month or two that you wear it, leading to follow-up visits to your prosthetist.

After you are fitted with your first prosthesis, your doctor should provide a prescription for physical therapy. Usually, you will see a physical therapist two to three times a week for 1-hour sessions. These sessions are important to ensure that you develop good habits while you relearn how to walk, using a prosthesis. You will typically start walking using a walker as you work to regain strength, balance, endurance and confidence. Your residual limb will continue to go through physiological changes as you use your prosthesis more, typically resulting in volume loss. If your rehabilitation process proceeds well, you might see your prosthetist on a monthly or bimonthly basis during this time period. It might become necessary for your prosthetist to fit your prosthesis with a socket replacement during this time frame due to significant volume loss in your residual limb; this can cause your original preparatory socket to become too large and adversely affect its fit. If so, you may be test fit again before you are fitted with another downsized laminated socket.

This process can take a few visits to your prosthetist to complete. Be aware that every socket you are fit with will feel different, which may require some getting used to and possible adjustments following the fitting.

If your rehabilitation has proceeded well to this point, you might not need continued physical therapy. By now, your residual limb may have stopped shrinking and reached a somewhat mature state. At this point, your physician might prescribe that you be fit with your definitive (final or permanent) prosthesis, assuming your preparatory socket no longer fits intimately. This may require test fitting again and additional visits to your prosthetist before a new laminated socket is fabricated.

Your prosthetist will also incorporate componentry into your definitive prosthesis that matches your current and/or potential level of activity, assuming your activity level has changed since originally being fit with your preparatory prosthesis. You may have progressed through the use of a variety of assistive devices (walker to a 4-prong cane to a single-prong cane) to the point where you can ambulate without an assistive device. However, not all lower-limb amputees are able to function safely without the use of an assistive device, depending on their overall health, determination and confidence. Be aware that for some amputees, prolonged use of an assistive device can enhance safety and reduce the potential for falls.

As you approach the end of the first year since your amputation, you will hopefully have become fairly comfortable with life as an amputee: You will have mastered using a prosthesis – putting it on (donning), taking it off (doffing), making adjustments to the number of socks being worn, etc.; your phantom pain will have subsided and your phantom sensations will have lessened or become more tolerable; you will have found that you are able to do many of the activities of daily living (ADLs) that you did prior to your amputation, but possibly in different ways; and you will have established a good relationship with your prosthetist, who you’ve seen many times during the past year and will continue to see on a regular basis in the future.

Immediate Post-Operative

Early post-operative mobilisation is very important. It assists with wound healing (as the pumping action improves circulation while walking), your general wellbeing and gets you up and going in society and in life in general.

It is very important that you know exactly what the process of rehabilitation involves after you have received an amputation. You should join a team consisting of at least a Surgeon, Prosthetist and Physiotherapist. Other members can be your wound care sister as well as a Psychologist. 

The days of walking only months after receiving an amputation are long gone. At our practice, we are a part of a team that knows the importance of an amputation done the correct way, quick mobilisation and proper gait training

The success of prosthetic rehabilitation starts on the theatre table. The Surgeon must know and understand what happens after a prosthetic amputation. Therefore the surgeon must know which componentry is going to be used, the height of the componentry, the type of suspension that is going to be used, the length of the residual limb etc.

In our team, I accompany the Surgeon in the theatre to ensure that he is aware of the specifics of the shape and length of the prosthetic limb and what needs to be done in surgery. Stump shaping directly after the amputation is very important. Excessive swelling is bad for wound healing; therefore, we fit a rigid dressing on the residual limb directly after the surgery. This begins the “coning”, healing process and protection of the residual limb and prevents knee contractures. This dressing is kept on for 8 days, 24 hours a day, and can be easily removed for wound inspection and cleaning.

After this period we fit “post-operation silicone liners” which are measured and fitted to size. The specific measured liner is rolled onto the residual stump and gives further compression. The liners improve blood circulation, protect the residual limb, prevent swelling and shape the residual limb. You, as the user, need to learn how to don and doff the silicone liner, as this is going to be a part of your continuous prosthetic set up. The liner is worn for a 2 – 3 week period, where you visit our practice once a week to take measurements and to receive a smaller size liner as your residual limb starts to shrink.

3 – 4 weeks after amputation, we start fitting you with a temporary interim prosthesis which is made in 2 hours. As further quick volume reduction occurs when you start walking, the prosthesis will only fit your residual limb for 6- 12 weeks.

After this period of wearing your interim prosthesis, the final prosthesis is manufactured and you can continue improving your mobilisation.

You can download the immediate post-operative manual for more detailed information and pictures.

Early Postsurgical

It is quite normal for people to feel depressed immediately after having a limb amputated. Exceptions to this would be patients who have had to deal with intense pain before surgery. More often than not this depression is quickly replaced by a determination to get back to a near-to-normal life.

After your surgery, your wound will be dressed with either a rigid or a soft dressing. A rigid dressing is made from Plaster of Paris while a soft dressing is made up of cotton bandages. Soft dressings are used in conjunction with elastic bandages to help circulation and to prevent swelling. These bandages are re-applied at regular intervals throughout the day.

As part of your healing process, you will be given a series of exercises to perform. These are very important as they are designed to prevent any tightening of the muscles in the stump. This is very important because muscles that have tightened prevent effective use of the prosthetic limb. It is extremely important that you carry out these exercises regularly, and diligently, in order to get the best benefit out of your prosthesis.

There are a number of positions that you should avoid as they are likely to to cause muscle tightening or contractures. Do not:

  • Allow the stump to hang over the side of your bed
  • Sit in a wheelchair with your stump flexed or bent
  • Place a pillow under your knee or hip
  • Place a pillow under your back causing the spine to bend
  • Lie in bed with your knees bent
  • Place a pillow between your thighs
  • Sit with your knees crossed
  • In order to get the best use of your prosthesis you should avoid these positions

Oedema Control

One of the risks following amputation surgery is oedema. This is a swelling caused by fluid trapped in the tissues of the stump, and is a common occurrence after a limb amputation.

The best way of controlling oedema is by bandaging the stump, and you will be taught the correct technique to use since it is you, the amputee, who will be expected to carry out this task. This is because under normal circumstances the bandage should be changed between four and six times every day, and at intervals of four to six hours. Whatever the circumstances, the bandage should never be left in place for longer than twelve hours, since this can cause complications. If at any time you should experience throbbing of the stump, you should take steps to immediately remove the bandage and rewrap it.

Bandaging is done with standard 4-inch wide elastic bandages, one or two being sufficient for the average adult. While you are bandaging the stump the elastic bandage should be kept at two thirds of its maximum stretch, so try testing this out with a short length of bandage before starting the technique.

Refer to the accompanying graphics when practicing the following bandaging technique, and remember to keep the bandage at approximately two thirds of its maximum stretch.

  • Hold the end of the bandage on the inside of the thigh above the knee and unroll it so that it passes diagonally down the outer side of the stump, around the rear of the stump.
  • Pass the bandage over the end of the stump at the inner side, then diagonally upwards over the outer side of the stump, behind the knee and around the inside of the thigh to your starting point above the kneecap.
  • Continue around the back of the knee, diagonally down the inside and then the front of the stump so that it passes over the end of the stump on the outside.
  • Continue in the same way until the whole of the stump is covered with bandage and the bandage is used up. Hold the end of the bandage in place with the special clips that you have been given. The bandage should be tightest where it passes over the end of the stump.

Remember that the bandage should be removed from the stump and replaced every four to six hours, and should never be left on for more than twelve hours.

Gait Training

The goal of every lower-limb amputee is to walk “normally” again. In the context of this article, “normal” is defined as a symmetrical gait pattern that falls within the “average” range in terms of posture, step length, rate of speed, limb positioning, etc.

But being a lower limb amputee presents many different challenges when it comes to ambulating safely and avoiding the exertion of excessive energy. Generally, the higher the amputation level, the more gait deviations, or what some would call limps, we can expect to see. This is because with each segment of the anatomy that is lost to amputation, more muscle, sensory receptors and leverage are also lost. As a result, the person with a higher amputation level typically has a less stable and less energy-efficient gait pattern compared to a person with a lower amputation level.

Almost all lower-limb amputees will benefit from gait training at some point in their recovery to help normalise the gait pattern. Recent amputees have the most to gain because using a prosthesis is a new challenge. Aside from pre-amputation exercises done under the supervision of a physical therapist, the initial training is provided by the prosthetist as part of the care during the fitting of the prosthesis.

This care includes aligning the prosthesis to ensure that the components or parts of the prosthesis are positioned in such a way as to optimize the gait pattern. At the same time, initial gait instructions are also provided by the prosthetist so that the person wearing the prosthesis is able to stand and walk with enough stability to ensure safety. This process usually starts with the parallel bars, often using a gait belt just in case the new amputee loses his or her balance. At this stage, it is best to involve a physical therapist for regular gait training sessions. Once it is determined that stability is consistent, the parallel bars can be traded in for a walker or crutches.

Eventually, many prosthetic wearers will progress to a single cane or even no assistive device at all. It should be noted that using some type of assistive device is not a sign of disability; instead, its use indicates that the person can be more functional with the extra stability it provides.

Even amputees who have worn a prosthesis for years can benefit from gait training. This could be in the form of occasional visits to the therapist for a “tune-up” or it could be to learn a new skill such as walking step-over-step up stairs, walking on uneven terrain or even running.

It is important that the prosthetist and therapist remain in close communication when gait training is occurring since any changes to the prosthesis will affect the gait pattern, and vice versa. This becomes critical when considering the sophistication of today’s prosthetic components and their need to be adjusted more carefully.

 Also, quicker gains can be made if the amputee has at least a basic understanding of how the prosthesis and its components work. Gait training provided by an experienced physical therapist is available in a variety of settings.

For the new amputee, training with the recently fitted prosthesis will probably occur in a rehab hospital or skilled nursing facility (SNF). Here, the basics will be covered, including side-to-side weight shifting, marching in place, balancing on one leg, and side-stepping. These techniques are usually performed with the parallel bars, often with the use of a full-length mirror so that posture and foot position can be observed. Sometimes, the training will take place in the amputee’s home by a visiting physical therapist. Although there is no access to parallel bars and other equipment, some view the opportunity to learn in a familiar environment with real obstacles as a worthwhile trade-off.

Another option is to travel to an outpatient physical therapy clinic to receive gait training in a more progressive setting. Here, the focus is usually on more advanced tasks such as walking without an assistive device, climbing stairs, traversing inclines, and walking at varying speeds. Some amputees will eventually master uneven terrain, walk while carrying bulky items, or even learn to run.

An exercise program will also be prescribed to increase strength and range of motion. This will improve the chances of reaching the functional goals. Many different techniques can be incorporated into the gait training sessions, but two seem to stand out. The first involves the teaching of “splinter skills,” where the gait pattern is broken down into a sequence of events that are practiced individually before putting them all together to build the gait pattern. The second technique is more of a “whole walking” approach so that the gait pattern is practiced all at once with little concentration on the individual events, instead relying on the body’s natural tendency to find the most stable and energy-efficient way to walk. The physical therapist and prosthetist may try either or both of these strategies to get the best outcome.

Communication and teamwork between prosthetists and physical therapists go a long way in helping amputees reach their goals with prosthesis. A person’s ability to ambulate with a prosthesis partially depends on confidence, and that can be developed with practice. Unfortunately, medical aids coverage sometimes tends to limit treatment options, but it is important that a person is willing to advocate for the best care – then make the most out of the opportunity by working hard and working smart.

When to Replace a Prosthesis

In order for an individual living with a limb difference or amputation to return to their family and/or workplace, they must be accurately fitted with a prosthesis that matches their own anatomy. The prosthesis must be constructed in such a way that it maximises their current or potential physical needs and activity level.

Each amputee has unique needs, whether they are a baby born with a limb deficiency, a teenager having an amputation for cancer, or a senior losing a limb because of vascular insufficiency or diabetes. However, one thing they all have in common is the need to be as active as possible, as people living a sedentary lifestyle are at risk for a range of secondary conditions (obesity, diabetes, the loss of another limb, cardiovascular disease, depression, and some other forms of cancer) that will cost the health system far more than the provision of well-fitting, well-constructed, functional prosthesis.

Unfortunately, the human body rarely maintains its exact same shape. Weight and/or muscle mass is gained or lost, and children grow. However, plastic, carbon and steel do not change, nor do they last forever. They have to be changed or replaced on a regular basis if the amputee is to remain a functioning member of society.

Prosthetics is a very specialized field. Practitioners need: mechanical and engineering knowledge so that they can build the devices; a thorough knowledge of anatomy and physiology so that they can understand how the device will work in conjunction with the human body and be able to fit it to each individual's musculoskeletal system; and a basic knowledge of gait analysis and gait training.
The following guidelines are an aid to determining when a prosthesis should be replaced:

  • The amputee's weight is no longer within the safety range for the components.
  • The components are no longer working to the specifications of the manufacturer.
  • The individual's activity level is no longer compatible with the components used, such that they are increasing the individual's net energy cost rather than decreasing it.
  • A specific component/module needs replacing, but the replacement is not compatible with the rest of the existing components.
  • So many changes/alterations have been made to materials that their structural integrity has been compromised.
  • It is impossible to increase/decrease the size of the socket and or frame without rebuilding the whole prosthesis.

In addition, if the prosthesis is modular, individual components should be replaced for the same reasons. The socket, the single most important part of a prosthesis, which consists of a flexible socket, a rigid frame and/or a socket interface, should be replaced for the following reasons:

  • The size and/or shape does not allow for weight bearing on the anatomically correct areas-this can either be because the socket is too big, too small or of an incorrect shape, which can lead to painful end-bearing or hammocking; this in turn may lead to verrucous hyperplasia and, in some instances, cellulites and systemic infection.
  • The materials have been manipulated (shrunk or stretched) to where the structural integrity of the materials has been compromised beyond the safety level.
  • The materials have cracked or broken.
  • The materials are not strong enough to bear the weight of the individual.
  • Suction suspension cannot be maintained due to a leak/breakdown in structural integrity.
  • Proper hygiene cannot be maintained.