Fitting the Pieces Together

Despite their differing roles, surgeons and prosthetists have the same goal for a patient after an amputation: an optimal outcome and the ability to return to their previous lifestyle. Collaboration and feedback between surgeons and O&P practitioners from presurgery to postsurgery can help to ensure proper prosthetic fit and the best outcome for a specific patient.

“The advantage of collaboration is a better surgery, not only from a technical standpoint, but also one that leads to a residual limb that is prepared to work effectively with a prosthesis that is best designed for an individual patient,” John Rheinstein, FAAOP, lower extremity specialist and clinic manager at Hanger Clinic in New York, told O&P News.

Rheinstein said he encourages surgeons to consider amputation a reconstructive surgery.

“It is not a failure but an opportunity for the patient to move forward and have the best outcome given the circumstances,” he said.

“The challenge is that amputation is still seen as a surgical procedure of failure, and it is not looked upon as a reconstructive procedure whereby the surgeon is trying to put the components of the multiple-organ system — muscle, bone, nerves, arteries, skin — back together again,” Jonathan D. Day, CPO, chief of prosthetics and clinical instructor in the Department of Orthopedic Surgery and Rehabilitation at the University of Oklahoma Health Science Center’s College of Medicine, said. “The negativity of a patient requiring an amputation needs to be lessened and looked at as more reconstructing the patient because we have all seen amputees who do amazing things.”

A critical part of that reconstruction is making considerations for the prosthesis that the patient could receive after surgery.

“Prosthetists should be the best informed folks about amputation surgery,” Rheinstein said. “A problem limb limits patient’s ability to function and makes it more difficult to get a comfortable fitting prosthesis. There are any number of technical problems that can go wrong during surgery which wind up costing the patient discomfort, time and anxiety.”

For example, if a transtibial residual limb is too long with insufficient tissue coverage or the distal bones are not treated effectively, a patient may not receive the components that are most appropriate for them and they may not heal well, especially if they are diabetic. In these cases, patients undergo rehabilitation for a longer period of time and often experience complications, according to Rheinstein.

“The sooner that a patient can get up and moving, the better off they are going to be. If the prosthesis is integrated into the surgical planning process, the patient will benefit.”

For upper limb prostheses, collaboration with surgeons can often reduce device abandonment rates, which are a major concern in upper limb amputation, according to Patrick Prigge, CP, FAAOP, clinical manager at Advanced Arm Dynamics in Minneapolis. “There is a higher incidence of reported abandonment rates in upper limb prosthetics because of a few main problems including lack of functionality and patients’ lack of involvement in the decision-making process,” he said. “The benefits of collaboration are that we get the opportunity to maximize the patient’s residual limb. We look at the soft tissue, the length of the bone, the stability of the bone and work to optimize the interface between the patient’s residual limb and the prosthesis to get the best outcome that we can. It involves a fairly thought-out plan and the patient can become part of the process.”

Prigge said he presents prosthetic options, the surgeon presents surgical reconstruction options and the patient makes the ultimate decision.

“We have a certain knowledge base, the surgeons have a different knowledge base, and if we blend the two together, there are opportunities to create something that did not exist before,” Prigge said. “It is simple synergy at its core.”

“A team approach with as much information as possible being available to the surgeon, prosthetist and rehab team is going to provide the best outcome for the patient,” said Jason Lalla, CP, a certified prosthetist at Next Step Bionics and Prosthetics in Manchester, N.H.

Communication and establishing collaboration

Collaboration between surgeons and prosthetists is often a result of building a relationship and establishing a history of working together.

“Once we have [completed] some cases together and we are working from the same assumptions, it becomes easier,” Rheinstein said.

Ultimately, establishing a partnership with a surgeon is up to the prosthetist.

“We as a profession should be encouraging better education and spreading the message to surgeons that the quality of amputations is very important,” Rheinstein said. “On a national level and even international level, I would like to see more communication so that surgeons get better training in amputation techniques. A poorly done amputation really disables a patient, and a well-done amputation enables a patient.”

Prigge has worked with surgeons in routine clinics where they meet with the patients to discuss their options, but he explained that the process of communication begins well before this time. He agreed with Rheinstein that the prosthetist should begin the dialogue. “It is the bringing of the worlds together and I do not think that is the surgeon’s responsibility to [initiate] that,” he said.

Often, developing a relationship with a surgeon begins as a referral relationship, but Prigge urged prosthetists to sit down with surgeons to learn from each other.

“If you offer so send patients to a physician, they are going to want to listen to you,” he said. “Ultimately that is where it starts and it opens up the door. Then you start having conversations about getting patients where you want to take them.”

Lalla suggested that prosthetists request to be part of pre-surgical consultations. For example, he will often go with his patient and meet with the surgeon in person.

“At that point, we are able to review X-rays or other test results together and discuss the plan for amputation as well as post-surgical care and fitting. When patients witness firsthand the collaboration between their physician and prosthetist, they tend to go into surgery feeling much more confident about what the outcome of their situation will be,” he said.

Ideally, collaboration would take place face-to-face with the patient present, but Rheinstein and others agreed that telephone conversations and emails with photos are adequate forms of communication. The keys to communication from both sides of the table are mutual respect and understanding.

“We as prosthetists have to understand the pressures and factors that make the surgeon’s job difficult and they have to understand what we are up against,” Rheinstein said. “If you can gain the trust and respect of a physician to the point where you are being treated as a professional, as a colleague, that improves communication.”

“An important key to communication is learning to speak the same language,” Aaron Fitzsimmons, CP, OT, FAAOP, of The Surgical Clinic, PLLC, in Nashville, Tenn., said. “The education pathway for O&P professionals currently is limited in certain aspects of medical terminology, regarding amputation surgery and comorbidities. Education for prosthetists should be more related to long-term care techniques and medical pathology and histology to bridge the educational gap and help O&P professionals become allied health professionals.”

A team approach

One group that has learned to speak the same language and collaborate in caring for patients is the team at the Amputee Clinic in the Department of Orthopedic Surgery and Rehabilitation at the University of Oklahoma College of Medicine. There, Day works closely with William J.J. Ertl, MD, orthopaedic trauma surgeon and medical director of the operating room, and Carol P. Dionne, PT, DPT, PhD, OCS, Cert MDT, associate professor in the Department of Rehabilitation Services, to ensure continuity of care for amputees who come to Ertl’s clinic. When patients are referred for consultation, they meet with the entire medical team of prosthetist, surgeon and physical therapist.

“When patients are sent in for consultation, either for primary amputation or secondary revision, we have been able to diagnose that it is not a limb-specific problem and we have been able to treat the patient through prosthetic changes,” Ertl said. “The flipside is that we have had patients come in so deconditioned or out of shape that it is more of a therapy intervention, a functional restoration intervention, instead of a surgical intervention. Instead of having one person try to decide how to treat a patient, we have a three-headed system in which we look at all aspects.”

This multidisciplinary approach streamlines the process for the patient: Patients receive care in one appointment rather than in three separate appointments at different providers across the state possibly separated by weeks, according to Day.

In some cases, patients see Ertl because they are not happy with the way their limb or prosthesis is functioning, but because of a lack of information, they may not realize that the issue is prosthetic. “Jonathan (Day) would be able to look at the patient, and a lot of times, it is a minor prosthetic adjustment,” Ertl said. “Sometimes we have been able to facilitate their prosthetic care even if Jonathan is not their primary provider.”

“There is beginning to be a transition to inter-professional team-based care to address all of the complex issues that surround amputation,” Dionne said. “It includes not just the patient’s immediate recovery from surgery, but also the fitness of the individual. Rehab intervention starts at the beginning and postoperative mobility is essential to combat mortality and morbidity in addition to ensuring that the patient can use their limb appropriately.”

Communication among team members at the University of Oklahoma is fluid: They are on the same campus, communicate through cell phone, and meet weekly to discuss cases. “Being located centrally allows us to have real-time flow of information for patient care and also real-time flow of information on research activities,” Ertl said.

“The three of us are available to our current patient population and as part of discharge planning from the hospital after the amputation,” Day added.

Dionne echoed Rheinstein’s comments about mutual respect and understanding. “Our team values each other’s roles, and that is huge,” she said. “We collaborate through the clinic and research, but we also work together teaching because this is a comprehensive health sciences center and our students feed off of each other. We try to promote the team-based approach.”

Types of information

When surgeons and prosthetists meet to discuss cases, certain pieces of information are important to communicate. For optimal prosthetic fit, surgeons should inform prosthetists of a patient’s comorbidities, the patient’s medical history, the surgeon’s expectations of the patient in rehabilitation and anything significant that happened during surgery, according to Rheinstein.

“This information helps us to better treat patients as well as communicate with payers,” he said.

Through in-depth consultations with surgeons, prosthetists can often help to improve outcomes for patients by accommodating changes that surgeons need to make during surgery. “I have seen scenarios where surgeons were intending to amputate a limb shorter than we thought would be necessary,” Lalla said. “In one particular case, surgeons were trying to avoid significant skin grafting, but as it turned out, after a longer discussion, it was something we were able to accommodate with interface and socket design and the outcome turned out positively.”

Surgeons and prosthetists should also discuss the patient’s goals, work history, activities of daily living and the lifestyle that they hope to resume postsurgery. “These considerations can sometimes determine the type of amputation, whether above the knee or below the knee, in some cases,” Lalla said.

According to Rheinstein, the surgical objectives that prosthetists need to communicate to surgeons for optimal prosthetic fit in amputation surgery include: a well-healed, pain-free limb, sufficient range of motion, mobile resilient tissue, adequate strength, functional length and shape and stability over time.

Prosthetists should also discuss socket design and interface materials with the surgeons.

“Those can often affect the outcome as well,” Lalla said. “There are definitely important considerations on our end, like skin issues prior to amputation when considering interface materials. The advancements in technology and materials we have can influence surgical procedures.”

Prigge typically meets with a patient and a therapist for a full 2-hour to 4-hour evaluation to discuss the patient’s options, desires and goals. After establishing basic information, he then informs the surgeon of the evaluation results and makes recommendations.

“During initial patient evaluations, I now will discuss all the surgical reconstruction options with patients including cadaver allografting, autografting, angular osteotomy, soft tissue revisions, limb shortening, tissue-free flap transfers for removal of problematic scar tissue or skin grafts and even up to the point of limb transplant among other options, because I have learned the value of these procedures from the surgeons,” Prigge said.

Similarly, Fitzsimmons said at his practice, the number of amputation techniques has expanded from two to six over the years because of mutual learning between prosthetists and surgeons. “O&P professionals need to be fluent in the surgical language of types of sutures, types of surgical tools, types of bone and types of muscular anatomy,” he said. “Those types of things are very important for them to become fluent in to join the surgical discussion.”

For during and after surgery, Fitzsimmons suggested that prosthetists be able to discuss optimal surgical tools for specific situations and wound care techniques and different types of compression levels.

Additionally, an important part of the process is feedback among the surgeon, prosthetist and physical therapist. “Prosthetists should be more assertive about providing feedback, good and bad,” Rheinstein said. “There is a natural tendency to try not to offend a referral source. I think feedback is very important, but there is not really a mechanism for it.”

Advances for the future

Currently there is no accepted way to grade the quality of amputation surgery, according to Rheinstein. Going forward, the establishment of a measurement to provide feedback would help to contribute to the field and ultimately improve outcomes for all patients. “There should be better ways of measuring and documenting the output from amputation surgery.”

Ideally, the measurement system would also take into account things like gait speed, patient satisfaction and pain. “The residual limb is really the foundation on which the whole prosthesis is built,” Rheinstein said. “Partnerships [between surgeons and prosthetists] could definitely improve amputation technique, improve prosthetic fitting and help the field move forward with new advances like osseointegration.”

In addition, more research is needed on the bone bridge technique, according to Rheinstein.

“In my clinical experience, these techniques are positive for patients, but I do think there is an opportunity for more research; we need a careful research study that goes beyond just the limb to the prosthesis and the patient’s clinical outcome,” he said.

One of Ertl’s research goals is to quantify and qualify the Ertl bone bridge technique, which was developed by his grandfather nearly 100 years ago. “Over the years, many aspects of that technique have gotten somewhat misunderstood and it has been misapplied,” Ertl said. “When it gets misapplied, there is a bad outcome or a challenging outcome and then the surgical technique gets criticized. So my goal is to study from a surgical research standpoint, what are the benefits of this amputation, and from a prosthetic standpoint, how can we fit the amputee with a more dynamic socket that incorporates the aspects of end bearing and maintaining bone health?”

Dionne, Ertl and Day are in the process of developing a model for risk for injury to the residuum to identify early specific factors that place people at risk, in an evidence-based effort to prevent or minimize those risks.

“We are working toward having more of a wellness approach to help patients stay in the community and remain productive, functioning members of society,” Dionne said.

Additionally, with the advent of new technology such as bionic prosthetics, prosthetists need to keep surgeons informed of what is available. “If surgeons are aware of what is components the prosthetist intends to use, surgical considerations may be made to accommodate some of the new technology, resulting in better patient outcomes and quality of life,” Lalla said.

Going forward, Fitzsimmons believes there should be more of an emphasis on O&P professionals as allied health professionals. “The platform for practice, the professional environment, needs to change so that O&P professionals are aligned with the other allied health care professionals on the same team either as part of the same health care system or part of the surgical group,” he said. “Unless you remove that business element, I do not know how care can move forward in a neutral way; it will always have a business slant to it.”

Prigge agreed. “There is a myth that prosthetists simply fill prescriptions, and another side of that is that we undervalue our role in the allied health community,” Prigge said. “We need to bridge that gap to become part of the team.” – by Tina DiMarcantonio

Disclosures: Day, Dionne, Ertl, Fitzsimmons, Lalla, Prigge and Rheinstein report no relevant financial disclosures.