Functional Outcomes of Elderly after Unilateral Diabetic Transtibial

Amputation: A Case Report

Elisabet Augustina, Melinda Harini

Department of Physical Medicine and Rehabilitation, Dr. Cipto Mangunkusumo National General Hospital,

Faculty of Medicine, University of Indonesia, Jakarta, Indonesia

Keywords: Functional, Elderly, Transtibial Amputation, Diabetes

Abstract: Foot ulceration is a major cause of morbidity in elderly with diabetes, as osteomyelitis and diabetic

gangrene lead to amputation. After undergoing transtibial amputation, patients were referred to

Rehabilitation Department for prosthesis prescription and rehabilitation to restore mobility and to

successfully reintegrate the patient into community. This study aims to identify the current patient’s

mobility, independence and mental status following amputations. This study was done between May 2017

and August 2018, four patients above 60 years old were referred to Medical Rehabilitation outpatient clinic

as candidates of prosthesis use after unilateral transtibial diabetic amputations. Mobility status, Barthel

Index, Mini Mental State Examination and Geriatric Depression Scale were evaluated through medical

records and interview. Two patients who completed rehabilitation programs, ambulate with prostheses

without obstacles and are mild dependent with current better mental status. Two patients who did not, are

moderate dependent ambulating with wheelchair. In conclusion, patients who completed rehabilitation were

more independent, ambulatory with prosthesis and have better mental status. Factors such as social living

conditions, initial cognitive and independence levels may be considered as functional outcome predictors.

Further investigation with better method and larger sample size is needed.

1 INTRODUCTION

Diabetes Mellitus (DM) is the leading cause of

nontraumatic lower extremity amputation in

worldwide. Approximately 15% of individuals with

DM develop a foot ulcer and a significant subset will

ultimately undergo amputation (Powers, 2015).

Every year more than one million people undergo a

lower limb amputation as consequence of

osteomyelitis and diabetic gangrene, which

calculates to a limb lost due to diabetes every 30

seconds in the world (Braun, 2014).

Diabetics have a 15-fold higher risk for lower

limb amputation. Risk factors for amputation among

diabetic patients include: male sex, diabetes more

than 10 years duration, peripheral neuropathy,

abnormal structure of foot (bony abnormalities,

callus, thickened nails), peripheral arterial disease,

smoking, history of previous ulcer or amputation

and poor glycemic control (Powers, 2015)

Transtibial amputation is the most common

amputation level seen in general practice. It is

performed one third of the way down tibia and a

posterior myocutaneous flap is used to cover the

residual tibia. At this length, the bulk of the posterior

compartment muscles are available for a flap

providing good soft tissue coverage over the distal

tibia and the primary vascular structures for the

lower limb are preserved in the flap (Clayton, 2009).

Rehabilitation management is crucial in the

postoperative period. Early mobilization facilitates

early functional improvements such as bed mobility,

transfers and mobilization to chair or wheelchair

(Lovegreen, 2015). Patients must be educated about

positioning, range of motion (ROM) and

strengthening exercises of the affected limb

(Frykberg, 2006). Initiation of aerobic exercise is

needed to increase endurance and cardiovascular

fitness. As the patient progress, focuses are more on

standing and balance in parallel bars and use of

walking aid (Brigham, 2011).

Prosthetic fitting and gait training can usually be

started within 3–6 weeks of surgery. Patients usually

ambulate independently within one month of starting

Augustina, E. and Harini, M.

Functional Outcomes of Elderly after Unilateral Diabetic Transtibial Amputation: A Case Report.

DOI: 10.5220/0009066301490153

In Proceedings of the 11th National Congress and the 18th Annual Scientiﬁc Meeting of Indonesian Physical Medicine and Rehabilitation Association (KONAS XI and PIT XVIII PERDOSRI

2019), pages 149-153

ISBN: 978-989-758-409-1

149

therapy using prosthesis. The residual limb

continues to shrink during the first 6–8 months.

After completing the final prosthetic evaluation, the

patient will require a period of gait training under

the supervision of the physical therapist (Lovegreen,

2015).

Rehabilitation programs are designed to

endeavor restoring functional mobility and to

successfully reintegrating the patient into

community. Functional outcomes of amputees have

been reported to be associated with early

rehabilitation intervention and adherence rate of the

patients to rehabilitation (Kosse, 2013). Most

literature defines functional outcome only in terms

of prosthetic use, but general measures of functional

outcome with or without prosthesis are equally

important (Van Eijk, 2012).

Factors such as age, Mini Mental State

Examination (MMSE) and Barthel Index (BI)

preoperative and at admission to rehabilitation are

correlated significantly with later functional status

(Van Eijk, 2011). Less use of prosthesis is

significantly related to age, female sex, cognitive

impairment, level of physical disability, possession

of wheelchair and dissatisfaction (Bilodeau, 2000).

Status of ambulatory and mental have reciprocal

connection in elderly with prostheses (Coffey,

2012). Patients with impairment in several areas of

cognition including memory, attention and

concentration, visuospatial function and

organizational skills will face significant challenges

in learning how to mobilize with prosthesis (O’Neil

2008; O’Neil, 2009). Meanwhile, one study found

that years after major lower extremity amputation,

amputees who do not use prostheses have more

symptoms of depression than those who use (Remes,

2010).

The purpose of this case series was to follow-up

and identify the current mobility, independence and

mental status of elderly patients one to two years

after unilateral diabetic transtibial amputation.

2 METHODS

Between May 2017 and August 2018, four patients

older than 60 years old post unilateral transtibial

amputation due to diabetic gangrene, were referred

to Department of Medical Rehabilitation outpatient

clinic, Cipto Mangunkusumo National General

Hospital, Jakarta for prosthesis prescription and

rehabilitation. The patients came within 1-4 months

after surgery. Data is collected through medical

records and interview during home visit. Informed

consent was obtained from the patients.

Patients’ status of mobility, independence and

mental were evaluated at the first consultation and

reevaluated during home visit on August 2019.

Evaluation of mobility status is by observing and

asking how the patient ambulate in daily life and the

use of prosthesis or other ambulatory aids. BI-100 is

used to evaluate the independence level of activity

of daily living (ADL). Mental status is evaluated

using MMSE and Geriatric Depression Scale (GDS).

Medical history and social living condition are

collected through medical records, interview and

observation.

3 RESULTS

Table 1 shows the baseline characteristics of the

patients. Among the patients are three males and one

female, with age range 61–67 years old and

amputation onset range 12–24 months with left legs

as predominant sites.

Table 1: Patients’ Characteristics.

A B C D

Age* 62 61 65 67

Sex Male Male Male Female

Leg sites

Amputation

onset**

Left

Right

Left

Post-operative

rehabilitation**

Rehabilitation

attendance***

58.3

100

66.7

*in years; **in months; ***in percent

Rehabilitation care included 30-45 minutes of

individual physical therapy, 2 times a week,

consisting of improving transferring, upper and

lower limb muscle strengthening, shaping residual

limb for prosthesis, range of motion exercise to

preventing flexion contracture of involved joint,

massage of soft tissue adhesions, preparing for

weight-bearing and prosthesis wearing. During

consultation and follow-up, patient and caregiver

were given education about stump care, positioning

(avoiding prolonged knee flexion), risk of fall, home

program and prosthesis use. There was no adverse

event, no history of new wound and hospital

readmission from all the patients.

Patient B and C completed the rehabilitation until

prosthesis fitting and training. Patient A and D did

KONAS XI and PIT XVIII PERDOSRI 2019 - The 11th National Congress and The 18th Annual Scientiﬁc Meeting of Indonesian Physical

Medicine and Rehabilitation Association

150

not do rehabilitation regularly. However, all of them

eventually got prosthesis which consists of patellar

tendon bearing socket, supracondylar cuff

suspension, exoskeleton shank and solid ankle

cushion heel foot. Table 2 shows comprehensive

geriatric assessment (CGA). The functional

outcomes (mobility, independence and mental

status) are compared between now and the first

consultation time. Figure 1 shows the progression of

patients’ mobility status between pre and

postoperative.

Table 2: Comprehensive Geriatric Assessment.

Patient Preoperative

Mobility Level

Current Mobility

Level*

Barthel Index

Then Now

MMSE

Then Now Δ

Geriatric

Depression Scale

Out: wheelchair

In: bedridden

Out: wheelchair

In: crutches

Out: crutches

In: crutches

Out: wheelchair

In: bedridden

Out: wheelchair

In: crawling/hopping

Out: prosthesis

In: prosthesis

Out: prosthesis

In: crutches

Out: wheelchair

In: wheelchair

52 68

92 98

88 92

66 64

27 24 3

28 28 0

29 27 2

24 19 5

*Out= outdoor; In=indoor

Figure 1: Mobility Status Progression.

4 DISCUSSION

Inspired by ICF (International Classification of

Functioning, Disability and Health) model, aspects

of health conditions, body structures and functions,

personal and environmental factors were evaluated

in this case-series. This study emphasizes on

mobility, independence of ADL and cognitive status

as body functions and presence of family support as

the environmental factors.

The importance of following-up mobility status

of elderly patients after lower limb amputation is

because mobility is the key component of

independent living, enabling the performance of

activities of daily living (Bilodeau, 2000; Geertzen,

2005). In this study, we found among four patients

with unilateral transtibial amputation due to

diabetes, two of them still ambulate with prosthesis

without obstacles. The other two patients only used

the prostheses first couple months because they felt

heavy and uncomfortable so they prefer wheelchair.

Patient A used to be bedridden for 3 weeks prior

to amputation. After getting prosthesis, he

complained of unfitness resulting skin excoriation

on stump but refused to repair due to financial

problem (as it is not covered by national health

insurance). Patient D was bedridden about 2 months

before amputation because refusing the idea of

amputation and seeking for alternative treatment, but

then post amputation, she gained ability on wheeling

and partially using walker before getting prostheses.

She apparently used prosthesis less than four months

Functional Outcomes of Elderly after Unilateral Diabetic Transtibial Amputation: A Case Report

151

and gradually became dominant wheelchair user, as

she found it easier and less fatigue.

The patients who no longer use the prostheses

apparently attended less than 70% of rehabilitation

sessions. They have similarities, in which they only

live with spouses who are also elderly with

disabilities. Patient A’s wife is a 60-year-old female

with obesity, knee pain, hypertension and frequent

headache, while patient D’s husband is a 78-year old

male with hearing problems and history of ischemic

stroke. They could only go to hospital if their

children or relative had time to accompany them.

Not only difficulty to access and caregiver, financial

issue also plays role. Rather than attending

rehabilitation, patient A prefers accompanying his

wife working (as street seller), as he quit working

few months pre-amputation. On the other side, two

patients who use prostheses attended rehabilitation

regularly because they have supports from spouses,

children or grandchildren who live together with the

patients.

Family support is an important facilitator of the

regaining ability to function by enabling social

participation and encouraging self-care. This fact

was evidenced by several studies in which

individuals receiving greater social support present

better health conditions, physical and psychological

performance, in addition to greater adherence of the

treatment (Junior, 2017). A study proved that

adherence to rehabilitation has significant benefit,

where patients who attended more than 80%

scheduled sessions, the mean muscle power score in

each side of the upper and lower limbs was

significantly better and degree of dependency

improved following rehabilitation (AlSofyani,

2016).

In this study, we found that BI score of patients

using prostheses was higher at initial compared to

the wheelchair patients and it increased at the

current condition. On the other side, the first

wheelchair patient has increased BI score but still

categorized as moderate dependent. The second

wheelchair patient in fact becomes more dependent

in ADL. This is highly possibly related to the

decrease of cognition. She has the highest decline of

MMSE score among four of them. The two

wheelchair patients are also categorized as probable

depression based on GDS.

This finding is similar with one study (Van Eijk,

2011) that found patients who completed

rehabilitation had increase of BI between first

admitted to rehabilitation and one year in the

afterwards (p=0.000), where patients who did not

complete had no significant increase (p=0.932). In

contrast, different from this result, previous studies

found that pre-operative functional is the most

important in predicting walking ability and

prosthesis use after lower limb amputation, where

post-operative functional status does not seem to be

related. It is also recommended that evaluation of

ambulation is useful rather than global functional

assessment (Sansam. 2009).

Studies also established significant relation

between cognitive abilities with the functional level

and prediction of prosthetic use, as learning skills

are important in order to adequately use prosthesis

(Lee, 2018; Van Eijk, 2012). Using MMSE,

cognitive status at 2-4 weeks after amputation was

found to predict 20% of variance in mobility at 8-14

months post lower limb amputation (Coffey, 2012).

The cognitive domains such as: memory, executive

function, visuospatial cognition and language

fluency are considered to be sensitive (Lee, 2018).

Depression following amputation in elderly,

based on one study, appeared had no statistically

significant relationship with prosthesis use

(Bilodeau, 2000). Factors associated with depressive

symptoms in lower limb amputees are female sex,

lack of social support, unemployment, shorter time

since amputation, smoking status and pain

(Hawamdeh, 2008). Both wheelchair patients have

similar risk factors: lack of support from family and

being unemployed. Additional risk factors are

smoking for patient A (as he still smokes

occasionally) and female gender for patient D.

This is the first follow-up case series about

functional outcomes of elderly transtibial amputation

due to diabetes. In this small case series, we note

limitation that this study only involved small

numbers of patients, thus making it difficult to

generalize the results for elderly amputees. This is

because we only recruited and followed-up elderly

transtibial amputees from Physical Medicine and

Rehabilitation residents’ case reports from 2017 to

2018. The other study limitation is related to the use

of functional outcome parameters. This study only

used status of prosthesis use, BI, MMSE and GDS.

One meta-analysis (Fortington, 2012) states that

there is still no standard of predictors or functional

outcome measures of lower limb geriatric amputees.

Further more comprehensive parameters involving

physical, mental and social aspects should be

utilized (Lee, 2018; Schoppen, 2003).

KONAS XI and PIT XVIII PERDOSRI 2019 - The 11th National Congress and The 18th Annual Scientiﬁc Meeting of Indonesian Physical

Medicine and Rehabilitation Association

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5 CONCLUSIONS

In conclusion, patients who completed rehabilitation

are more independent, ambulatory with prostheses

and have better mental status. Factors such as

MMSE and BI, as well as patient’s social living

conditions may be considered as functional outcome

predictors for the elderly patients undergoing

diabetic transtibial amputation. The predictors could

assist in determining suitability prosthetic or

ambulatory aids use, ascertaining appropriate and

realistic goals so that maximal mobility and

independence are achieved. In this case, further

investigation with better method and larger sample

size is needed.

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