Abstract

Purpose: This paper presents the case of an individual with a transmetatarsal amputation and diabetic ulcer on the medial plantar aspect of his right foot and answers the following PICO question via evidence based analysis: What is the role of physical therapists in improving functional outcomes in patients with a transmetatarsal amputation? Background: Limb preservation is very important to all people to sustain quality of life. The decision to amputate is never made lightly. Reasons for amputation include vascular insufficiency, ulceration, injury, tumor, infection among other reasons. If it is indicated, a transmetatarsal amputation is a good option to improve functional mobility and ambulation, to greater preserve the limb and to avoid the need for a prosthetic limb. If successful, post transmetatarsal patients require few changes to their daily lives. However, if the surgery fails there is a 35% chance of higher amputation. The main predictors of higher amputation are a non-healing wound and having a non - ambulatory status. In the acute and inpatient rehabilitation setting, there is an opportunity for physical therapists to promote optimal healing and safe ambulation in this population and to provide adequate information regarding limb protection. With a re-amputation rate as high as one in three, there is indication for physical therapists to play a larger role in the recovery from a transmetatarsal amputation. Case Description: Mr. A is a 60-year-old male admitted to the hospital for diabetic ketoacidosis with associated altered mental status and atrial fibrillation, has an extensive history including poorly controlled type 2 diabetes mellitus, severe peripheral vascular disease, a 6-month history of a right transmetatarsal amputation which currently presents with an open wound on the medial plantar aspect with concern of infection and he has an open-reduction internal fixation (ORIF) implant on his left tibia. Mr. A underwent several incision and drainage (I and D) surgeries for his right foot ulcer as well as his left ankle, as a new abscess was discovered in his left foot, in order to clean out infected tissue. During Mr. A's hospital stay physical therapy was ordered in order to ambulate and assess his functional mobility. After spending several weeks in the hospital and unfortunately suffering a left below knee amputation in the end, Mr. A was discharged to an inpatient rehabilitation facility. Outcomes: A review of the current evidence reveals that there is implication for physical therapy to play a role in improving outcomes in patients with transmetatarsal amputations however there is limited research looking at the effectiveness and methods that may be utilized to do so. The evidence shows that interventions geared towards strengthen hip extensors and flexors, treatments that improve ankle range of motion and gait training may all be effective in this population. This review highlights which patients are at risk for skin breakdown and that unhealed skin breakdown is a leading cause for higher amputation. Physical therapist can play a role in ambulating these patients post-operatively and should be aware of the risk of skin breakdown especially with weight bearing activities. Discussion: This case presentation describes a patient who presented with a new transmetatarsal amputation with an unhealed wound and since his first evaluation, higher amputation was in discussion. The aim of this investigation was to determine what physical therapy interventions might have been utilized to promote healing, protect against further breakdown and what strategies could be used in future cases to prevent skin breakdown from occurring in the first place. Most of the current research is looking at surgical interventions and there is limited research looking at conservative methods of improving outcomes in this population, and most of the relevant research is dated without much recent evidence to be found. However, from the available research, many risk factors and limitations were identified in these populations and areas of which intervention could be focused including: footwear modification, hip strengthening and implementing walking strategies to avoid skin breakdown. The patient presented in this case study had a huge set back in his rehabilitation as infection was found in his other leg which required a trans-tibial amputation. Preservation and protection of his right transmetatarsal amputation became extremely important and the focuses of his treatment during his hospital stay.

Provenance

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Document Type

Capstone

Keywords

Amputation; Articular Range of Motion; Physical Therapists

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