Arthroplasty and Amputation in the Elderly Adult

Objectives

1. Arthroplasty vs Amputation

2. Common Causes

3. 3 Continuum of Care

4. Focus Areas of Treatment

5. Patient and Family Education

= Arthroplasty vs. Amputation1,2 =

== A. Arthroplasty is a surgical procedure to restore the function of a joint. A joint can be restored by resurfacing the bones. An artificial joint (called a prosthesis) may also be used. ==

== B. Amputation is the removal of all or a body part that is enclosed by skin. This can occur at an accident site or by a surgical procedure. ==

= Common Cause =

== A. Osteoarthritis (OA)3: As we age, common stressors applied to the joints over time cause natural degenerative changes. Additionally, in the older adult population a change in bone mineral density with several areas of influence increase the risk of developing OA. Often, these changes become unbearable to tolerate with daily activities and have surpassed the level of benefiting from physical and lifestyle changes. Between 1995 and 2005, the annual number of knee arthroplasties in patients with a primary diagnose of OA increased from 4,916 to 14,565, an increase of 196%. ==

== B. Diabetes Mellitus (DM)4,5: The most common form of amputation is lower extremity, and more often, toe amputations. The most prevalent population undergoing such procedure are those with diabetes. Elderly persons newly diagnosed as having DM experienced high rates of complications during 10-year follow-up, far more than elderly persons without this diagnosis, implying a substantial burden on the individual and on the health care system. ==

= Continuum of Care6,7 =

== A. Preoperative Education about the procedure should be provided from the surgeon. It is appropriate to discuss pain management early as there will be new goals of reducing phantom limb pain in the future. Studies show that peer visitations also help to improve patient outcomes and attitudes. ==

== B. Surgery/Acute Care will include an extensive care team. Each member should play a role in dressing the wound/limb, checking for the healing of the residual limb, and work to control pain through techniques of massage and mirror box therapy. Dressings will also help manage the pain experienced by the individuals. ==

== C. Physical Therapy Settings will vary depending on the need of the individual. It is important to consider the resources the person has attainable at home or nearby. Often, after arthroplasty surgeries, several days in the hospital are utilized before the patient is safe to be discharged. In consideration for the individuals home set-up and available caregivers, it is important to decide to what degree they will need assistance. To go home with recommendation of home health PT is appropriate early on before they can schedule an outpatient rehab session. This is a slow process for both population. If he individual requires more extensive care they may be more appropriate for a skilled nursing facility. This decision should be screened by the PT and ultimately discussed by the entire care team. ==

= Focus Areas of Treatment =

== A. Self-Mobility and Pain Management are very important with both populations as the trauma done with the surgical procedure often leads to increased contractures at the joint above or at the surgery. Informing the patient and the caregivers of the proper way to provide passive range of motion to prevent these contractures and permit optimal functional mobility in the future, is very key. ==

== B. Strength and Ambulation: The lower extremity will greatly need additional strength training exercises. However, it is also indicated and important to provide stability exercise and the core for improved balance with functional activities. ==

== C. Cardiovascular Endurance8: After a surgical procedure, there are minor cardiovascular changes that occur as the body resets itself from the experienced trauma. Additionally, the elderly population experience increase stress to the CV system after undergoing surgical procedures as well as taking the medications provided to manage the new pain. These populations are also more likely to have had a decrease in overall CV function prior to the surgical procedure, which in turn, reduced their overall function. Introducing a walking program when the individual is ready is optimal. For starters, utilizing as arm ergometer will allow the patient to begin stressing the CV system early while recovering from their surgical procedure. ==

= Patient and Caregiver Education =

== A. Support Group6: When they have fully recovered and rehabilitated from their amputation, consider them becoming a peer mentor to others, as it helps others starting out on the journey tremendously, AND it shows them how far they’ve come. ==

https://www.rehab.va.gov/asoc/
http://federalpt.org/members/special-interest-groups/

https://www.amputee-coalition.org/limb-loss-resource-center/resources-filtered/video-resources/

References

1) Restoring Joint Function with Arthroplasty. (n.d.). Retrieved from https://www.hopkinsmedicine.org/healthlibrary/test_procedures/orthopaedic/arthroplasty_92,P07677

2) Definition of Amputation. (n.d.). Retrieved from https://www.medicinenet.com/script/main/art.asp?articlekey=12537

3) Otten, R., PM, V., & Picavet, H. (2010). Trends in the number of knee and hip arthroplasties: Considerably more knee and hip prostheses due to osteoarthritis in 2030 [Abstract]. Europe PMC, 154(A), 1534th ser. doi:PMID:20619009

4) Diabetes. (n.d.). Retrieved from https://www.amputee-coalition.org/limb-loss-resource-center/resources-filtered/resources-by-topic/diabetes/

5) Bethel MA, Sloan FA, Belsky D, Feinglos MN. Longitudinal Incidence and Prevalence of Adverse Outcomes of Diabetes Mellitus in Elderly Patients. Arch Intern Med. 2007;167(9):921–927. doi:10.1001/archinte.167.9.921

6) Prognostic Differences for Functional Recovery After Major Lower Limb Amputation: Effects of the Timing and Type of Inpatient Rehabilitation Services in the Veterans Health Administration. (2010, April 27). Retrieved from https://www.sciencedirect.com/science/article/pii/S1934148210000316

7) Http://www.hangerclinic.com/new-patient/ampower/Documents/Stages_of_Amputation_and_Rehabilitation.pdf. (n.d.).

8) Carli, F., & Zavorsky, G. S. (2005). Optimizing functional exercise capacity in the elderly surgical population. Current Opinion in Clinical Nutrition and Metabolic Care,8(1), 23-32. doi:10.1097/00075197-200501000-00005