General Principles & Postoperative Instructions
It is the science dealing with the artificial replacement of external parts of the human body, in cases of amputations or congenital limb deficiencies. Prosthetics belong in the scientific field of Biomechanics, which includes the research and analysis of the human system (muscles, skeleton and nervous systems), in order to contribute to the field of biomedicine. Prosthesis is a device used characteristically to replace, as much as possible, the body part which is lost in cases such as:
- Peripheral vaso-circulatory failure (62%)
- Accident (26%)
- Cancer (6%)
- Congenital limb deficiency (1%)
- Infectious disease (5%)
Ideally, the prosthesis should be easy to implement; the patient should be able to apply and remove it easily from the body; it should be made of lightweight and durable material and have a pleasant aesthetic effect.
The prosthetic professional constitutes an integral part of the clinical team (doctors, physiatrists, physiotherapists, nurses) and deals with the measurement, design, construction and application of an artificial limb (prosthesis). The prosthetic contributes and plays a major role in the proper restoration of amputations. The success in the rehabilitation process is to ensure the social welfare of the patients by offering the required services.
The prosthetic rehabilitation in some cases may begin even before an amputation takes place. The patient should have an active role in all phases of recovery, even in the pre-operative stages, as in several cases such a surgery requires the patient’s consent. Thus, if they understand the possibilities offered to them after a possible amputation, they could make the most logical decision to optimally restore their health. The clinical staff of our company is frequently called in this primary stage to play an advisory role, undertaking the responsibility to thoroughly explain the technical procedures, during the rehabilitation period, as well as the levels of functionality that can be achieved when the rehabilitation process is completed.
Some of the questions born to patients should be answered in their very first meeting with our staff; such questions are:
What impact will the amputation have to the rest of my life?
Goal for every patient is to regain the life they had before the amputation. Many people believe this is not possible, but this is not true. People with amputations can still enjoy the habits he had until now. They just cannot execute them in the same way. They continue to deal with most of them, but they have to learn to execute them in a different way. By equipping the patient with a technically acceptable prosthesis, we help them to return to his daily occupations in a more natural way.
How can this certain loss be dealt with optimally?
The amputation is one of the most emotional and traumatic events that a human can experience. For every person, the time needed for him to deal with the loss and cope with the practical problems of everyday life varies. However, with a collective effort made by the medical personnel, the prosthetic professional and the family, the negative consequences could be minimized and the positive benefits highlighted.
What will my insurance cover?
Our company undertakes to inform you about the percentage of coverage for each patient by their insurance, as well as the period of time in which they are entitled to a new construction or repair of the old one. Furthermore, we inform you about the general benefits provided by the Social Welfare Fund.
What will be the level of functionality after my recovery?
Our priority is to assist the patient to regain the level of functionality he/she had before surgery, whether it is to return actively back to his/her workplace or to have his home, his daily routine and the desired independence. If the imputation occurs after a chronic condition, our target is to help the patient regain an even higher level of functionality than that he/she was experiencing before the surgery.
The sooner the answers become available to the patient, the less likely is to create negative emotional effects, which would inevitably lead to complications and stall the recovery phases.
The interim between the amputation and the initial prosthetic application varies among patients. It usually lasts 6 to 8 weeks. In this period of time, the assistance of the physiotherapy is considered significant and has three primary purposes:
Maintenance/Improvement of muscle condition
Maintenance of full mobility of the residual limb
Reduction of the postoperative edema and formation of the abutment
It is important to start the recovery process as soon as possible, because this increases the chances for greater success. On the contrary, a large delay increases the risk of various physical and mental complications, such as muscle spasms, general weakness and depression.
The prosthetic rehabilitation is divided into two (2) stages: the postoperative phase, which is the time between the surgical and the prosthetic application, (and of course it includes the decision not to apply the prosthesis) and the prosthetic phase, which starts with the construction of a temporary prosthesis and lasts up to the delivery of the permanent prosthesis.
It is applied mainly on lower limb amputations and as implied by its name, it will be applied temporarily to the patient to assist him in the rehabilitation phase. Just because the residual limb (abutment) tends to change shape and volume for a period of time after the surgical operation in the certain phase, the temporary prosthesis will provide the desired mobility to the patient during this stage.
The construction of the temporary prosthesis begins when the stitches have been removed and a large percentage of the edema has subsided. The prosthetic makes the necessary measurements using plaster and completes partially the prosthesis. The temporary artificial limb will be used by the patient for 5 to 7 weeks. During this period the patient will be in continuous contact with his/her prosthetic for all the necessary adaptations in his/her socket, while the edema subsides. The patient should follow the instructions for the proper maintenance of the abutment and not neglect the exercises at home. To improve the proprioception, the balance and their muscular status, they should gradually increase the levels of intensity, especially after the implementation of the temporary prosthesis.
In order to start the construction of the temporary prosthesis, the abutment should have obtained a size as fixed as possible. Because it still shrinks even after the implementation of the permanent prosthesis, the more stable it is the largest will be the period of a good implementation of the socket. Our concern is the correct application of the prosthesis in all stages of recovery, whether it is a temporary prosthesis or a permanent one.
The bandages protect the surgical incisions, while controlling the postoperative edema of the abutment. The edema control is vital, as an uncontrollable edema could cause unbearable pain and stall the recovery process. The postoperative bandaging can be rigid, of moderate compression, controlled or soft.
Based on the instructions given by the attending physician, immediately after the surgical operation an elastic bandage of moderate compression is applied. During the first days in the hospital, the bandages should be replaced regularly, because its constant application results in lower elasticity. The nursing personnel should explain to the patient or his relatives the proper application of the bandage. Then, if the trauma is healed, the bandage of moderate compression is replaced by elastic abutment socks.
The elastic socks can be easily worn and are equally as effective as the elastic bandage in controlling the edema. Their implementation should take place after the stitches are cut and the exsiccation of the abutment has been completed. They are knitted with reinforced thread, having a conical or cylindrical shape and are available in various sizes for their implementation in tibial or femoral amputations. Due to the fact that the abutment’s volume will be reduced shortly, several times the patient is provided with smaller size socks.
It is very important for the prosthetic professional to be close to the patient as soon as possible after the surgical operation. An initial examination will help to assess the patient and lead to a successful rehabilitation. At the same time, the prosthetic will prepare him to use the prosthesis and give him a list of exercises at home. This is the moment when the prosthetic and the patient will begin to build a personal relationship of trust, which will last for a lifetime. In any case, the patient should feel comfortable with his/her prosthetic professional, be able to speak openly to him about his/her concerns and feel that the prosthetic and the technical personnel would be engaged to provide the best solution to his/her problem.
The prosthetic professional, based on his experience, assesses the general condition of the patient (medical and psychological), the ability they have to find their balance (with or without help), their transitions and their rehabilitation progress. These are factors which would help us categorize the patients based on their activity levels (K1, K2, K3, and K4) that are estimated to be achieved with the completion of rehabilitation.
Levels of Activity
K1 CATEGORY: (Indoor Walker). The patient has the ability to use the prosthesis at low speed on level ground in order to be transferred. The time and the distance that can be covered are significantly reduced due to his/her general pathological condition. Objective: To restore the patient’s ability to stand and move limitedly indoors.
K2 CATEGORY: (Limited outdoor walker). The patient has the ability to move slowly with the prosthesis and to face environmental obstacles such as curbs, stairs and uneven ground. The time and the distance that can be covered are significantly limited due to their general pathology. Objective: To restore the patient’s ability to stand and move both indoors and outdoors.
K3 CATEGORY: (Outdoor Walker).
The patient has the ability to move with the prosthesis at a variable rate and simultaneously to face the majority of the environmental obstacles. They have the ability to move outdoors and are able to deal with professional activities which do not enforce to the prosthesis mechanical requirements above average. The K3 category also includes those who have a higher need for security, due to secondary conditions (additional handicaps, special living conditions) combined with moderate to high mobility. Objective: To restore the patient’s ability to walk and to move without limitations not only indoors, but also outdoors with imperceptible restrictions.
K4 CATEGORY: (Outdoor walker with stringent requirements)
The patient has the ability to walk as a walker in the K3 category. The time and distance that can be covered are not limited. In addition, due to the higher operational requirements, the prosthesis should maintain a high level of quality as far as vibrations, tense situations and rotations are concerned. Objective: To restore the patient’s ability to walk and move without limitations both indoors and outdoors.
We examine the abutment in order to test its muscular abilities, its anatomy, the range of movement and we map the tolerant and non-tolerant to pressure areas. We assess the patient’s ability to preserve his balance and take into account possible allergies during material selection. The examination of the abutment is very important and repeated tests and accurate measurements are needed for the proper construction of the prosthetic socket.
Construction of the Permanent ProsthesisCon
When the edema of the abutment has subsided and the patient’s movements have been improved, we are ready to begin the construction of the permanent prosthesis. This is constructed partly or totally from scratch, based on each case. A new plaster cast of the abutment will be necessary in all cases, because its perimeter will have changed. Actually, in some cases, the utilization of new types of joints is strongly recommended.
We are called to create the prosthesis, an artificial limb, which will offer to the patient comfortable walking and safe support in their everyday activities and at the same time will be aesthetically acceptable. Our experience has shown that the optimal rehabilitation is provided through professional cooperation. The significance of this cooperation is based on the realization that the key component in lower limbs prostheses is the stump-socket interface and the prosthetic socket with the assistance of both the surgeon and the prosthetic professional. If the final target of the surgeon is to create a useful and functional abutment, the first target of the prosthetic professional should be the creation of a useful and functional socket to mount the prosthesis.
For the successful operation of the prosthesis and the effective transfer of all loads, we have to ensure proper dimensions for the abutment’s socket, as well as conditions with functional grip. In addition, the utilization of the appropriate joint and foot mechanisms is considered necessary, combined with the proper mechanical response. Furthermore, the configurations of the onwards-backwards and the central-sidelong alignment are vital, as well as the final aesthetic integrity of the structure.
Regarding the aesthetics of the abutment, we can apply a cosmetic foam cover or a silicone glove in the color of the skin of each patient. Our long presence in the field of prosthetic rehabilitation and our continuous development, combined with the technological progress, provides us with the ability to construct highly sophisticated prostheses and the patient with a great advantage for a successful rehabilitation. The aim is to ensure the needed means to facilitate the daily life of the patient and through strengthening to achieve maximum autonomy and social welfare. Our company provides the necessary walking training (kinesiology), in order to restore the patient’s ability to preserve his/her balance by strengthening the muscular system and improving the patient’s fitness.
A successful construction of an artificial limb is not enough for the patient to achieve normal walking. It is important to train the patient in a disciplined walk with the prosthesis. Several times, the necessary attention to the patient’s training is not provided, leading to a very limited walking ability, which deviates significantly from the normal one. The training involves fitness exercises to strengthen the patient and raise his/her flexibility.
Initially, we place the patients on parallel bars and ask them to carry out a simple stand. It is a great challenge for them to be able to stand on their two feet, after the application of the prosthesis. If they succeed in controlling their weight on the prosthesis, they will be able to slowly regain their balance. Then, they start making small and steady steps, using the support provided by the bars. At the same time, the professional staff of CRC is focused on strengthening exercises and improving the proprioception.
When these goals are fulfilled, the patients should gradually raise the mobility levels, until they feel ready to walk without support. The walking training is characterized as a personalized program, but the use of a cane is considered necessary in most cases. The cane is always used on the opposite side of the prosthesis and is moved in parallel with it. When the patients stop using the cane, it is necessary to be accompanied by someone, for any eventuality. Supported, the patients feel safe, have better balance and are encouraged.
Finally, the patients need to practice alone, as much as possible, in safe and familiar environments (home, workplace) for them. It is important that these spaces are adapted to the needs of each patient, thus facilitating their safe walking. The patients will obtain the required mobility and improve their confidence in social activities. The target is the patient to be able to walk freely, with maximum autonomy and no functional limitations.