A 35 year old diabetic Aboriginal women, who underwent a right transtibial amputation for diabetic foot ulcer and completed prosthetic rehabilitation: Amputee Case Study

Contents

Title

A 35 year old diabetic Aboriginal women, who underwent a right transtibial amputation for diabetic foot ulcer and completed prosthetic rehabilitation.

Abstract

Mary is a 35-year-old Aboriginal woman who underwent R TTA for a large severe diabetic foot ulcer (~5x5 cm area) on the plantar and medial aspect of the 1st metatarsal head, osteomyelitis and dry gangrene. Mary also had necrosis of the Left 3rd toe, which she had amputated at the same time as her R TTA. Mary completed prosthetic rehabilitation to successfully use a prosthesis.

Key Words

Transtibial amputation; Aboriginal; Diabetes

Client Characteristics

Mary is a 35-year-old Aboriginal woman. Mary is unemployed and is currently receiving a disability benefit. She has not worked in paid employment since leaving school at age 15 years. Mary enjoys spending time with her friends, walking and going to concerts and events. Mary does not drive.

Medical diagnosis: Chronic diabetic foot ulcers as described above progressed to dry gangrene and osteomyelitis of the R 1st metatarsal head requiring R TTA. Dry necrosis of the L 3rd toe requiring amputation at the 3rd MTPJ. Post op orders by the surgeon were to mobilise out of bed Day 1 and for weight bearing as tolerated on the L foot with post op shoe fitted by prosthetist/orthotist ensuring no pressure through the L 3rd toe surgical wound.

Past medical history includes: Type 2 diabetes mellitus (diagnosed 10 years ago; poor BSL control requiring Metformin); peripheral neuropathy bilateral lower limbs to knees (no problems with retinopathy or nephropathy at this stage); chronic diabetic ulcers bilateral feet R>L over the past 2 years; asthma (requiring Ventolin prn). Good cognitive function and ability to follow instructions, accepting of requirement for amputation. 10 pack year history of smoking, current smoker 5 cigarettes per day. Previous care: Has been seen by Endocrinology and Vascular Outpatients over the past 2 years. Poor compliance with diet recommendations and BSL monitoring and control.

Examination Findings

Subjective: Chronic bilateral diabetic foot ulcers over the past 2 years as described above. Poor sensation due to peripheral neuropathy, little associated pain so not compliant with crutches or walker to off load ulcers. Mary does a lot of walking as she does not drive (~2 km per day). This has likely contributed to the ulcers not healing. Mary lives at a wheelchair accessible hostel close to the city centre.

Short term goals:


  1. To mobilise with a self propelled wheelchair independently and be discharged home (to local wheelchair accessible hostel) within 2 weeks when medical clearance has been given.

  2. To commence prosthetic training when R TT wound and L 3rd toe amputation wound have fully healed (within 3 months).

Long term goals:


  1. To walk independently with a single point stick with prosthesis within 4 months.

  2. To walk unaided with prosthesis with a normal gait without significant deviations within 6 months.

Self Report Outcome Measures:
Through completing this course (Week 2 notes), I am now aware of the Activities Specific Balance Confidence Scale (ABC-UK) and the Prosthesis Evaluation Questionnaire (PEQ) which we did not use at the time.

Physical performance measures:
 Bed mobility required minimal assistance day 1 post op and progressed rapidly to independence by day 2. Transfer mobility bed to chair minimal assistance day 1 post op progressing to supervision by day 2 with prompts for safe technique and independence by day 3. Able to sit to stand independently at parallel bars (wearing orthotic shoe to off load pressure through L 3rd toe amputation surgical wound) by day 5. Mobilising independently in self propelled manual wheelchair once IV line/PCA out day 3 post op.

Objective: Full joint ROM upper limbs and lower limbs including hip extension 30 degrees bilaterally and full bilateral knee extension and L ankle dorsiflexion. Full strength 5/5 all muscle groups but slightly decreased hip extensor endurance (only able to do x 10 reps of closed kinetic chain bilateral bridging L and R hip).

ICF findings: (Physiopedia Week 2 notes)
 Body Functions and Structures: Muscle endurance of the hip extensors reduced bilaterally. Static and dynamic standing balance and transfer balance affected by the modified footwear required to protect the Left 3rd toe amputation site. No problem with phantom limb pain or post op pain. Reduced sensation L lower limb up to the knee.

Activity Limitations: Standing limited by need to protect L 3rd toe amputation wound until fully healed. Once this wound fully healed and prosthesis fitted Timed Up and Go test was performed initially with walker then with single point walking stick as gait progressed. Time improved by 3 seconds by discharge. 6 Minute Walk test was also performed at this time (no wounds on L foot) and improved by 1 minute between first assessment and discharge 2 months later.

Participation Restrictions: We could have used the PEQ. Mary used her manual wheelchair instead of walking to meet up with her friends. She was not able to attend concerts/events until she was walking independently with her prosthesis with a walking stick and had good stump skin tolerance resistant to breakdown at 5 months post R TTA.

Environmental factors: Mary lived in a wheelchair accessible hostel so she was able to easily access her home and mobilised outdoors with a manual wheelchair on discharge from hospital at day 10 post op.

Clinical Hypothesis

Mary's main problems are:


  1. Reduced hip extensor endurance bilaterally.

  2. L 3rd toe amputation surgical wound requiring protection and limiting mobility; reduced sensation L lower limb and associated diabetic vascular changes increasing risk of injury to this limb if not protected;

  3. R TTA surgical wound needing monitoring and full healing prior to prosthetic fitting. Delayed healing by fall onto stump at 3 weeks post op.

Intervention

  1. Pre prosthetic exercise programme focussing on increasing the endurance of the hip extensors for prosthetic gait including closed kinetic chain hip extension bridging exercise starting bilaterally on day 1 post op with 3 sets of 10 reps and progressing to single leg bridging 3 sets of 30 reps by 4 weeks post op. and doing this exercise with legs on the theraball (double leg then single leg). Exercise programme also included prone ly stretches to maintain hip extension ROM; hamstrings stretches; hip abduction strengthening and endurance starting with open kinetic chain in side ly day 1 post op 3 sets of 10 progressing to adding theraband resistance and 3 sets of 30 reps by 2 weeks post op.
  2. Protecting L 3rd toe amputation site by ensuring patient wears orthotic post op shoe fitted by prosthetist/orthotists and patient education on correct transfer technique with out hopping or twisting forces.
  3. Stump oedema control: Initially fitting double layer tubigrip compression once first post op dressing taken down by surgeon and wound looking good colour with wound edges together, stitches in situ (posterior flap wound) at day 3 post op over top of light Primapore dressing. Progressed to fit Juzo sock compression at day 1 post op just prior to discharge home. Education to keep stump elevated and use stump support with wheelchair (not let stump hang down).
  4. Fitting of R TTA prosthesis once stump wound and left 3rd toe amputation wound fully healed at 2 months post surgery. Prosthesis fitted: PTB with pelite liner and cotton socks interface. SACH foot initially for stability fitted progressing to dynamic foot at 5 months once mobilising independently unaided with the prosthesis. Patient able to return to her normal supportive sports shoe footwear once left 3rd toe amputation wound fully healed. Education re: ongoing life long care, daily monitoring and protection for this foot and minimising forces through this foot and seeking medical review at the first sign of redness or breakdown. Teaching appropriate use of prosthesis and regular monitoring of stump skin for signs of breakdown and sock markings to help determine correct fit.
  5. Prosthetic exercise programme including: initially teaching weight bearing and weight shifting in the parallel bars progressing to step up lunges with the L foot up onto a step, stepping then walking in the parallel bars with prompts/facilitation for heel contact, weight transfer over the prosthesis, prosthetic hip extension. Mirror and video feedback for gait quality. Side stepping holding rail progression to braiding. Progression to wheeled walker then elbow crutches. Ball rolling under L foot, throw and catch ball in parallel bars progressing to standing on foam, wobble board in parallel bars. Backwards walking and figure 8 walking in and out cones. Clock face stepping progressing by increasing speed and crossing midline initially with walking stick. Functional training with prosthesis including up and down stairs with rail and ramps/slopes indoors and outdoors, escalator practice with walking stick initially.

Outcome

  1. Improved hip extensor endurance from closed kinetic chain hip extension bridging exercise starting bilaterally on day 1 post op with 3 sets of 10 reps and progressing to single leg bridging 3 sets of 30 reps by 4 weeks post op. and doing this exercise with legs on the theraball (double leg then single leg) able to achieve 3 sets of 30 reps single leg on theraball both sides by 6 weeks post op. Hip and knee ROM maintained.
  2. L foot protection and self monitoring improved with no further wounds or ulcers in the time patient was seen until discharge from regular outpatient follow up at 6 months post op.

  3. R TT stump wound healing progressed well for first 3 weeks with Juzo sock fitted. Delayed then by fall onto stump which opened up about 3 cm along surgical scar line requiring mepilex dressings and fully healed about 4 weeks later with a further week of Juzo sock compression prior to prosthetic casting and fitting at 2 months post op.
  4. Prosthetic training with PTB prosthesis commenced at 2 months post R TTA when wounds had fully healed. Progression limited initially by decreased compliance with advice to gradually increase weight bearing time on prosthesis and fragile scar line due to re-opening of wound post fall at 3 weeks post op. 2 cm fragile area on scar line continued to blister for ~6 weeks combined with irregular attendance delaying prosthetic training. Once skin settled progressed well to achieve her long-term goals above. Prosthetic modifications by the prosthetist due to the fragile scar line included trial of silicon sock, which was unsuitable due to excessive sweating causing discomfort and increasing skin breakdown.Success was achieved by the prosthetist grinding out the pelite liner in the fragile scar line area and inserting some light foam to ensure contact so the skin didn't blister and fill with fluid but decreased pressure on the fragile area along with applying hyperfix over light melanin dressing over fully healed area of fragile skin to provide additional protection and limit friction on skin until skin tolerance improved after about 3 weeks.
  5. Mary gradually increased her time wearing her prosthesis and was wearing it all day and mobilising independently with a single point walking stick by 5 months post R TTA and mobilising independently with no significant gait deviations by 6 months post R TTA and able to negotiate basic obstacles encountered in the community such as stairs (advised to continue to hold rail where available), slopes, ramps and escalators with a normal gait pattern.
  6. Timed Up and Go test was performed initially with walker then with single point walking stick as gait progressed. Time improved by 3 seconds by discharge.
  7. 6 Minute Walk test was also performed at this time (no wounds on L foot) and improved by 1 minute between first assessment and discharge 2 months later.

Discussion

Mary is a young Aboriginal women who underwent R TTA for diabetic ulcers who was ultimately able to achieve her goals and mobilise independently with a prosthesis.
[1]

  • PVD and diabetes are the major reasons for lower limb amputation surgery. [2]
  • Incidence of amputation is higher in smokers, rises with age and is higher in men than women 2:1[1]
  • Lower limb amputations account for the majority of all amputations. [2]
  • People with diabetes make up about half of all amputees in the UK. [2]
  • One Australian loses a lower limb every 3 hours as a direct result of diabetes related foot disease'. [3]
  • 30% increase in diabetes related amputations in Australia over the past 10 years [3]).

  • Diabetes among Indigenous Australians (Aboriginal people) was 3 times as common as in non-Indigenous Australians in 2004-5. [4]
  • The prevalence of diabetes is as high as 30% in some Aboriginal communities [5]. Due to Mary's history of chronic diabetic ulcers and non compliance with mobility aids to off load the ulcers to allow healing, it was vital to educate her about self monitoring and protecting her remaining limb with socks and appropriate footwear and to seek medical review as soon as any red marks or trauma is noticed. It was also important to ensure that she wore the appropriate orthotic shoe to minimise pressure through the site of her left 3rd toe amputation and educate her in the correct transfer technique to minimise forces to this area. Life long precautions and protection of her remaining limb are vital to minimise the risk of further amputation. It was vital to protect this Left foot from day 1 post surgery when transferring out of bed by ensuring appropriate dressings applied and sock and shoe fitted by the prosthetist/orthotists prior to transferring out of bed and to educate the patient on the correct technique to transfer slowly and ensuring minimal rotational forces through the foot. In order to protect the Left sound remaining limb we did not progress mobility by hopping with a fore arm support walker or crutches but focused on aiming to progress to independent pivot transfers between the bed, wheelchair and toilet, independent bed mobility, independent mobility with a wheelchair with R stump support to maintain R knee extension range of motion and prevent dependent R stump oedema and L foot plate to protect the L foot.
  • It is important to protect the patient's contralateral limb during mobility training. [6]

References

  1. 1.0 1.1 Payne, C. B. (2000). Diabetes-related lower limb amputations in Australia. MJA, 173(7):352-354 Physiopedia Week 2 notes: ICF framework.
  2. 2.0 2.1 2.2 Harker, J. (2006). Wound healing complications associated with lower limb amputation. www.worldwidewounds.com
  3. 3.0 3.1 Bergin, S.M. et al (2012). A limb lost every 3 hours: can Australia reduce amputations in people with diabetes? MJA, 197(4), Aug 2012:197:198
  4. Australian Institute of Health and Welfare AIHW www.aihw.gov.au/diabetes/populations-of-interest/
  5. Diabetes Queensland www.diabetesqld.org.au/about-diabetes/diabetes-information
  6. Lee, S., and Harkless, (2006). Risk of Re-amputation in Diabetic Patients Stratified by Limb and Level of Amputation: 10 year observation. Diabetes Care, March 2006 29(3) 556-570