1. STUMP CARE, PHANTOM LIMB PAIN ,
GAIT TRAINING IN LOWER LIMB
HARSHITA YADAV
M.P.T (ORTHOPAEDICS)

2. AMPUTATION
• Derived from the Latin amputare.
• "to cut away", from ambi- ("about",
"around") and putare ("to prune").
• Amputation is the complete removal of an
injured or deformed body part.
• The English word "amputation" was first
applied to surgery in the 17th century.

3.  Amputation is the calculated surgical removal
of all or part of an extremity when its blood
supply is irreversibly compromised by disease
or severe injury.
(Medical Disability guidelines)
 The national center for Health Statistics
estimated that more than 300,000 patients
with amputations live in the US.
DEFINATION
INCIDENCE
( Campbell’ s operative orthopaedics , vol 1, 7th ed.)

4.  The reported annual incidence of LLA related
to peripheral vascular disease has ranged from
approximately 20 to 35 per 100,000 inhabitants.
 It has been reported that one in four diabetic
individuals develops peripheral vascular
disease that, when severe, may require
amputation .
(Incidence of Lower-Limb Amputation in the Diabetic and
Nondiabetic General Population; Diabetes Care 32:275–280,
2009)

5.  Amputation can be regarded as a treatment and not tragedy
Indications :-
1. Dead ( or dying ) limb
 Peripheral vascular disease ( 90% )
 Sever trauma
 Burns
 Frostbite
2. Dangerous limb
 Malignant tumors
 Lethal sepsis
 Crush injury leading to Crush syndrome

6. 3. Damn nuisance
Retaning the limb is more worse than having no limb at all
…. Because of :-
 Pain
 Gross malformation
 Recurrent sepsis
 Sever loss of function

7. CAUSES
o CONGENITAL ACQUIRED
- Vascular
- Trauma
- Infection
- Neoplasm
- Iatrogenic
- - Neuropthic
(Rehabilitation S Sunder 3rd ed.)

8. CONGENIAL ANOMALY

9. PERIPHERAL VASCULAR DISEASE

10. TRAUMA (severe tissue damage) –
traumatic amputation

11. MALIGNANT TUMOUR

12.  SCLERODERMA

13. DIABETES CRUSH INJURY

14. BURNS FROTBITE

15.  90 % amputation – peripheral vascular disease
 Young patient – trauma/ malignancy
 Absolute indication – irreversible ischaemia:
disease or trauma
( Campbell’ s operative orthopaedics , vol 1, 7th ed.)
 70% of lower-extremity amputations result from
complications associated with diabetes mellitus
and peripheral vascular occlusive disease.
 Peripheral vascular compromise, resulting from
diabetes mellitus, leads to multiple health
problems, including poor ability to heal wounds,
infections, ischemia and neuropathy .Due to these
factors, people who have diabetes are 15 times
more likely to have an amputation.
(The Influence of Lower-Extremity Muscle Force on Gait Characteristics in
Individuals With Below-Knee Amputations Secondary to Vascular Disease ,
APTA ; Vol – 76 )

16. PRINCIPLES
GENERAL SURGICAL
PRINCIPLES PRINCIPAL
(Rehabilitation S Sunder 3rd ed.)

17. GENERAL PRINCIPLES
 To save as much limb as possible while
providing a residual limb that is able to
tolerate the stress of the prosthesis and return
to mobility .
SURGICAL PRINCIPLES
 The use of tourniquet is advised to obtain a
bloodless field – except in ischemic
conditions.
 Level of amputation – effort should be made
to preserve all possible limb length, keeping in
mind the prosthesis to be fit.
(Rehabilitation S Sunder 3rd ed.)

18.  Skin flaps – skin should be mobile ,
sensation intact , and without adherent
scars.
 Muscles are divided 3 to 5 cm distal to the
level of bone resection.
 Nerves are gently pulled and cut cleanly so
that they retract well proximal to the bone
level. This reduces complication of
neuroma.
(Rehabilitation S Sunder 3rd ed.)

19.  Several studies have suggested guidelines to help ,to decide
which limb is salvageable. Most of these studies have
concentrated on severe injuries of the lower extremity.
 Most authors would agree with Lange’s absolute indications
for amputations of type3-C open tibial #, which include
complete distruption of the tibial nerve or a crush injury with
warm ischemia ,time of more than 6 hrs.
 Lange’s relative indications for primary amputation include:
* Severe associated injuries
* Severe ipsilateral foot injuries
*Anticipated protracted course to obtain soft- tissue
coverage and tibial reconstruction
DESIGN MAKING FOR THE SALVAGEABLE LIMB

20.  Other authors have attempted to remove subjective decision
making process.
 To predict which limbs will be salvalgeable, available scoring
systems include :
• the predictive salvage index,
• the limb injury score,
• the limb salvage index,
• the mangled extremity syndrome index, and
• the mangled extremity severity score.
 Of these , it was found that the mangled extremity severity
score was to be most useful.
( Campbell’ s operative orthopaedics , vol 1, 7th ed.)

21. ( Campbell’ s operative orthopaedics , vol 1, 7th ed.)

22. 1. MYODESIS -
o Muscles & fasciae are sutured directly to the distal
residual bone through drill holes.
o Muscles inserted function better , resulting in good
prosthetic control.
o Procedure compromises blood supply to the muscles
& hence is contraindicated in patients with severe
peripheral vascular disease.
o Sometimes myodesis fails even with best care.
(Rehabilitation S Sunder 3rd ed.)
SURGICAL PROCEDURE

23. 2. MYOPLASTY –
o Procedure require surgeon to suture the opposing muscles in
the residual limb to each other & to the periosteum or to the
distal end of the cut bone.
o Muscles must be stretched enough so that they control the
residual limb.
o Muscles sutured to each other provide distal soft-tissue
padding over the residual bone.
o Sometimes a painful bursa develops between the soft tissues
& underlying bone and some of these bursa can become
infected & painful.
3. OSTEOMYODESIS –
o Similar to myodesis but the periosteum is stripped. This
enables bone growth in that area.
(Rehabilitation S Sunder 3rd ed.)

24. TYPES OF AMPUTATION
(classified according to the surgical technique or the
emergency of situation)
1.PROVISIONAL
Used when primary healing is unlikely or delayed because
of infection, ischemia, or inadequate wound debridement.
It is done as an emergency procedure , to save the life of
the patient.
2. DEFINITIVE
Used after provisional amputation as an elective surgery.
In this, level is well- defined & thought out, with the
ultimate prosthesis kept in mind.
(Rehabilitation S Sunder 3rd ed.)

25. 3. ACCORDING TO THE ANATOMICAL LEVEL
Depending on whether the amputation is through the joint or
the bone, these may be defined as:
 Disarticulation: amputation through joint
 Through the shaft of a long bone
(Rehabilitation S Sunder 3rd ed.)

26. LEVEL OF AMPUTATION IN
LOWER LIMB

27.  HEMICORPORETOMY
Amputation both lower
limbs & pelvis below
L4- L5 level
HEMIPELVECTOMY
Resection of lower half of
the pelvis
(Physical rehabilitation;Susan B O’ Sullivan; 5th )

28. HIP DISARTICULATION
Amputation through hip joint ;
pelvis intact
 SHORT TRANSFEMORAL
(Above knee)
Less than 35% femoral length
(Physical rehabilitation; Susan B O’ Sullivan; 5th )

29. TRANSFEMORAL(above knee)
Between 35% & 60% femoral length
 LONG TRANSFEMORAL(above
knee)
More than 60% femoral length

30. KNEE DISARTICULATION
Amputation through the knee
joint; femur intact
SHORT TIBIAL(below knee)
Less than 20% tibial length

31. TRANSTIBIAL(below knee)
Between 20 -50% of tibial length
LONG TRANSTIBIAL (below
knee)
More than 50% tibial

32. SYME’S AMPUTATION
Ankle disarticulation with
attachment of heel pad to
distal end of tibia. Many
include removal of malleoli &
distal tibia/ fibular flares
TRANSMETATARSAL
Amputation through mid
section of all metatarsals

33. PARTIAL FOOT/ RAY
RESECTION
Resection of the 3rd, 4th , 5th
metatarsals and digits
TOE DISARTICULATION
Disarticulation at the
metatarsal phalangeal joint .

34. PARTIAL TOE
Excision of any part of one or more
toes

35. Closed amputation one in which flaps are made from the
skin and subcutaneous tissue and sutured over the end of the
bone.
Amputation in contiguity amputation at a joint.
Amputation in continuity amputation of a limb
elsewhere than at a joint.
Double-flap amputation one in which two flaps are
formed.
Elliptic amputation one in which the cut has an elliptical
outline.

36. Teale's amputation amputation with short and long
rectangular flaps
Gritti-Stokes amputation amputation of the leg through
the knee, using an oval anterior flap.
Guillotine amputation one performed rapidly by a circular
sweep of the knife and a cut of the saw, the entire cross-section
being left open for dressing.
Racket amputation one in which there is a single
longitudinal incision continuous below with a spiral incision on
either side of the limb.

38. Boyd’s amputation at the ankle with removal of the talus
and fusion of tibia & calcaneous
Spontaneous amputation loss of a part without
surgical intervention, as in diabetes mellitus.
Subperiosteal amputation one in which the cut end of
the bone is covered by periosteal flaps.
Chopart's amputation amputation of the foot by a
midtarsal disarticulation.
Lisfranc's amputation amputation of the foot between
the metatarsus and tarsus.

40.  Approximately 60,000 transtibial and transfemoral amputations
are performed each year in the United States alone.
(Gait Training With Virtual Reality–Based Real-Time Feedback:Improving Gait
Performance Following Transfemoral Amputation; September 2011; Volume 91
Number 9 Physical Therapy)
Multiple studies, have documented the increased
rehabilitation rate in BKA vs AKA patients, with more
than 65% of BKA patients ambulating with prosthesis.
In contrast, less than one third of AKA patients are
likely to rehabilitate with the use of a prosthesis.
(Major Lower Extremity Amputation; Arch Surg. 2004;139:395-399)

41.  Likely, due to the significant comorbidities of patients
undergoing amputation for ischemic disease, perioperative
mortality rates range from 0.9% to 14.1% for BKA patients
and are significantly worse for AKA patients at 2.8% to 35%.
(Major Lower Extremity Amputation; Arch Surg. 2004;139:395-399)

42. POST – OPERATIVE DRESSINGS
DRESSINGS
RIGID
DRESSINGS
SEMI-RIGID
DRESSINGS
SOFT
DRESSINGS
SHRINKERS ELASTIC WRAPS

43. REMOVAL RIGID DRESSINGS
NON REMOVAL RIGID
DRESSINGS

44. SEMI-RIGID DRESSINGS
ELASTIC SOFT DRESSINGS
SHRINKERS

45. COMPLICATIONS
HAEMATOMA
DEHISCENCE
/WOUND
BREAKDOWN
PROBLEMS
ASSOCIATED
WITH THE
SURROUNDING
SKIN
BONE EROSION/
OSTEOMYELITIS
INFECTION
TISSUE
NECROSIS
STUMP
OEDEMA
.
PAIN
(Wound healing complications associated with lower limb amputation
29-Sep-2006 15:28:16 BST)

46. TISSUE NECROSIS DEVELOPING
ON A STUMP WOUND CAUSING
WOUND BREAKDOWN.
EXTENSIVE TISSUE NECROSIS TO A
STUMP EXTENDING BELOW THE
SUTURE LINE CHARACTERISED BY
DISCOLORED, CYANOSED
BLISTERING
CONTACT DERMATITIS TO THE
DISTAL END OF A STUMP CAUSED BY
THE APPLICATION OF TAPE.
(Wound healing complications associated with lower limb amputation
29-Sep-2006 15:28:16 BST)

47. A DEHISCED ABOVE-KNEE
AMPUTATION WOUND EXPOSING
THE FEMUR.
STUMP SINUS MASKING UNDERLYING
OSTEOMYELITIS.
(Wound healing complications associated with lower limb amputation 29-
Sep-2006 15:28:16 BST)

48. Classified as:
PREPROSTHETIC
1. Delayed healing
2. Skin adherence to
bone of residual limb
3. Problems in shaping
of residual limb
4. Contractures
5. Chronic wound
sinus
POSTPROSTHETIC
1. Painful residual limb
2. Adherence of skin to
bone
3. Insensitive skin
4. Poor Fit
5. Boney overgrowth in
children
6. Degenerative arthritis
7. Fractures
(Atlas of Limb Prosthetics: Surgical, Prosthetic, and Rehabilitation Principles)

49. Knee flexion contracture that
occurred from a failure to
apply postoperative rigid
dressing following transtibial
amputation.
Appositional overgrowth of
the humerus in an
adolescent transhumeral
amputee.
(Atlas of Limb Prosthetics: Surgical, Prosthetic,
and Rehabilitation Principles)

50.  The phantom is the sensation of the limb that is no
longer there. The phantom, which usually occurs
initially immediately after surgery, is often described
as a tingling, burning, itching or pressure,
sensation, sometimes a numbness.
 Phantom sensation may be painless although, most
people find it uncomfortable & often report it as
pain; it usually does not interfere with prosthetic
rehabilitation.
(Physical rehabilitation;Susan B O’ Sullivan; 5th )
PHANTOM LIMB PAIN

51.  Phantom pain and sensations are defined as
perceptions ranging from slight tingling to sharp,
throbbing pain or aching that patients perceive
relating to an extremity or an organ that is physically
no longer a part of the body.
• It has been reported in various trials that the
estimated prevalence of phantom pain varies from
49% to 83%.
(A Retrospective Trial Comparing the Effects ofDifferent Anesthetic Techniques
on Phantom Pain After Lower Limb Amputation; 2011 Elsevier HS Journals)

52.  Amputees can experience two different types of pain:
incisional stump pain and phantom pain.
Stump pain is localised to the area immediately
around the stump and the amputation scar and is
described by patients as 'pressing', 'throbbing',
'burning' and 'squeezing'
(Wound healing complications associated with lower limb amputation 29-Sep-2006
15:28:16 BST)

53. Phantom pain is a common problem, affecting
between 8% to 10% of patients and is usually
reported during the immediate postoperative
period but can persist for up to two years. In some
cases, phantom pain can be a lifelong experience.
 It is literally pain experienced in the limb that has
been amputated, and is often described as a
crushing, tearing pain.
(Wound healing complications associated with lower limb amputation 29-Sep-
2006 15:28:16 BST)

54.  The pain may be localized or diffuse; it may be
continous or intermittent & triggered by some
external stimuli.
(Physical rehabilitation;Susan B O’ Sullivan; 5th )

55.  The neuromatrix is defined as a neuronal
organization that is genetically determined within
individuals and modified by sensory experiences.
According to this theory, abnormal impulses that
reach the neuromatrix after an extremity amputation
change the neuromatrix pattern, and this causes
conversion of normal input to pain sensations, in
other words, causes phantom pain.
(A Retrospective Trial Comparing the Effects ofDifferent Anesthetic Techniques
on Phantom Pain After Lower Limb Amputation; 2011 Elsevier HS Journals)

56.  The interference of normal impulse traffic to the
brain and excessive impulse discharge from
damaged neurons after amputation are believed to
be responsible for occurrence of phantom pain.
Additionally, somatosensory pain memory can
awaken after amputation, thus leading to phantom
pain.
(A Retrospective Trial Comparing the Effects ofDifferent Anesthetic Techniques
on Phantom Pain After Lower Limb Amputation; 2011 Elsevier HS Journals)

57.  In amputees with phantom limb pain, regional
anaesthesia at the stump causes both rapid
reduction in cortical reorganisation & elimination of
phantom limb pain, although phantom limb pain
returns as anaesthesia subsides.
(Is sucessful rehabilitation of complex regional pain syndrome due to sustained
attention to the affected limb? A randomised clinical trail; G. Lorimer Mosely*
;pain;2004;11,024)

58. Non invasive treatments such as US, icing, TENS,
or massage have been used with varying success.
Mild non-narcotic analgesics have been of limited
value; biofeedback, guided imagery, psychotherapy,
nerve blocks, & dorsal rhyzotomies have been used
with inconsistent results.
(Physical rehabilitation;Susan B O’ Sullivan; 5th )
MANAGEMENT FOR PHANTOM LIMB PAIN

59. Pain relief associated with mirror therapy, may be
due to the activation of mirror neurons in the
hemisphere of the brain that is contralateral to the
amputated limb. These neurons fire, when a person
either performs an action or observes another
person performing an action. Therefore , mirror
therapy may be helpful in alleviating phantom pain in
an amputated lower limb.
(Mirror Therapy for Phantom Limb Pain; E NGL J MED; 357;21;2007)

60. PHYSIOTHERAPEUTIC
MANAGEMENT
PRE-OPERATIVE
• ASSESSMENT
• STRENGTH TRAINING
POST-OPERATIVE
 PRE-PROSTHETIC
• ASSESSMENT
• STUMP
STRENGTHENING
• STUMP TRAINING FOR
PROSTHESIS
POST-PROSTHETIC
• GAIT TRAINING
• STUMP HANDLING

61. PRE-OPERATIVE MANAGEMENT
Training involves:
• Breathing exercises
• Strengthening exercises
• Mobilization exercises
• Bed mobility
• Transfers
• Stabilization exercises
• Wheelchair training
Strengthening exercises
Bed mobility and transfers
Wheelchair
training

63. POST-OPERATIVE MANAGEMENT
The aims of treatment are:
• Prevention of joint contracture
• To strengthen and mobilize unaffected leg
• To strengthen and co-ordinate the muscles controlling
the stump
• To strengthen and mobilize the trunk and retrain
balance
• To teach the patient to regain independence in
functional activities
• To control oedema of the stump and commence early
ambulation
• Re-education of sensation in healed stump
• Successful discharge into community

65. Cardiac precaution
Oedema control can be done by
following methods:
• Elevation and exercises
• Bandaging
• Shrinker socks
• Rigid dressing
• Intermittent pressure machines
• PPAM aid: pneumatic post
amputation mobility aid

66. Care of the Stump
– Keep the stump clean, dry, and free
from infection at all times.
– If fitted with a prosthesis, you should remove it before
going to sleep.
– Inspect and wash the stump with mild soap and warm
water every night, then dry thoroughly and apply talcum
powder.
– Do not use the prosthesis until the skin has healed.
– The stump sock should be changed daily, and the inside
of the socket may be cleaned with mild soap.

67. RESUDIAL LIMB WRAPPING
Eary wrapping provides a no. of positive
benefits:
o Decrease odema & venous stasis
o Assist in shaping
oHelp in counteract contracture
oProvide skin protection
oReduce redundant tissue problems
o Reduce phantom limb sensation and discomfort
oDesensitize the residual limb with local pain

68. Residual limb wrapping

71. Post-operative stump training
• Exercise
• Massage
• Pressure
• Mobilization
• Strengthening
PPAM aid for pressure
tolerance training

73. Short arc quadriceps

74. Straight Leg Raise

75. Ankle Pumps

76. Side Lying Hip Abduction - Modified

77. Side Lying Hip Abduction - Advanced

78. Prone Hip Extension

79. Prone Hip Extension (Sound Limb)

80. Prone Adductor Squeeze

81. Prone Knee Flexion

82. Push-ups

83. Quadruped Leg Lift

84. Abdominal Curl-up

85. Bosu Head Twists

86. Bosu Ball Exercises

89. Prosthetics
It is a replacement of
substitution of a missing or a
diseased part

90. Types of Prosthesis
BELOW KNEE
KNEE
DISARTICULATION ABOVE KNEE
HIP
DISARTICULATION
PROSTHETICS
LOWER EXTREMITY

91. Ideal prosthesis
1. Fits comfortably
2. Function well
3. Looks presentable
4. Fit as soon after the operation

92. Classification
Endoprosthesis- implants
used in Orthopaedic
surgery eg; austin moore
Prosthesis
Exoprosthesis-external
replacement for a lost part
of the limb

93. Temporary –
Used following amputation
till paient is fitted with
permanent prosthesis
eg;pylon
Permanent prosthesis

94. Lower Limb Prosthesis
Types of lower limbs prosthesis :
 Types of L.L. prostheses depend on
different stages after amputation.
 There are three types:
- Immediate post- operative prosthesis
- Temporary prosthesis
- Definitive prosthesis

95. DONNING
&
DOFFING

96. Center of gravity