radectomy

Preoperative Care. Unless time is a factor, as in emergency cases demanding immediate surgery, the preoperative care of the potential amputee should include emotional and vocational aspects as well as the physical. If patients are fully involved in plans for their rehabilitation, understand what is expected of them, and know the regimen of exercise and skills they will need to develop, their chances of full recovery and achievement of independence will be greatly enhanced. Much emotional support and encouragement can be offered by other amputees who are successfully mastering their prosthesis and making progress toward their goal of total rehabilitation.

Patients undergoing amputation will need help in dealing with the changes in body image as they adjust to the loss of a limb. They should be encouraged and given the opportunity to express feelings of anxiety, grief, anger, and depression, and given guidance in working toward a healthy acceptance of their handicap.

In general, physical preparation of the patient undergoing surgical amputation includes measures to promote optimum health and well-being, to establish nutritional and fluid balances, and to increase muscular strength and endurance levels. A program of exercises may be started to help the patient develop skill in using an overhead trapeze, crutches, and a walker and transferring from wheelchair to bed.

Postoperative Care. The residual limb is watched for hemorrhage, edema, infection, and ischemia. Some bleeding is not unusual but should rarely be more than a modest red stain on the dressing. Ischemia may be caused by a constricting dressing or the development of edema. Ischemia is recognized by the presence of excessive pain.

Traction was formerly commonly used after guillotine amputations but is rarely used nowadays. Generally such stumps are closed by delayed primary closure on the fourth or fifth day after amputation to save time in the hospital and accelerate rehabilitation.

Fitting of a prosthesis may be delayed or immediate depending on the condition of the patient and the reason for the amputation. Immediate fitting of a prosthesis involves the application of a rigid plastic dressing which serves to protect the stump and prevent edema. The dressing is similar to a cast and the patient will require cast care. The temporary prosthetic device is applied at the time of surgery and includes a pylon and foot-ankle assembly.

Early ambulation is a major advantage of immediate fitting of a prosthesis. Other benefits arise from the local compression exerted by the dressing. This serves to inhibit bleeding, to mold and help shrink the stump, and to reduce phantom sensations, pain, and contractures. Unfortunately, not all amputees are candidates for immediate fitting. The technique is not advised for amputations above the knee or above the elbow, for weak and debilitated patients, or for those who are mentally or emotionally unable to cooperate with efforts at rehabilitation. The procedure also requires the services of prosthetic experts.

The more conventional, and probably more frequently chosen, technique of delayed prosthetic fitting requires special care of the stump and a gradual preparation of the patient for weight-bearing and ambulation. During the immediate postoperative period the stump dressings are changed or reinforced as ordered. The stump usually is wrapped with elastic bandages or covered with stump socks. The bandages are checked frequently for signs of bleeding and for slippage, which may lead to a tourniquet effect and the occlusion of blood supply. Exercises are started as soon as possible, regardless of the surgical approach, in order to strengthen the muscles and prevent contractures.

The patient with amputation of an upper limb also may receive immediate or delayed fitting of a prosthesis. When the surgeon has chosen the delayed fitting technique, the patient requires stump care similar to that for the lower limb except that an upper limb stump is bandaged more loosely, especially when amputation was the result of trauma. Exercises are begun the day after surgery and within ten to fourteen days the patient is fitted with a temporary prosthesis.