What is the recommended multidisciplinary postoperative management for a patient after a below‑knee amputation?

Multidisciplinary Postoperative Management After Below-Knee Amputation

A multispecialty care team should evaluate and provide comprehensive postoperative care with goals of complete wound healing, minimizing complications, and preservation of ambulatory status. 1

Core Team Composition

The postoperative management team must include 1:

• Vascular specialists (vascular medicine, vascular surgery, interventional radiology)
• Podiatrists or orthopedic surgeons for biomechanical assessment and foot care
• Wound care specialists for stump healing optimization
• Physical and occupational therapists for early mobilization and prosthetic training
• Prosthetists for timely prosthetic fitting
• Endocrinologists (especially for diabetic patients)
• Infectious disease specialists when infection is present
• Physical medicine and rehabilitation clinicians
• Nutritionists to address malnutrition
• Social workers for psychosocial support

Immediate Postoperative Phase (Days 0-7)

Wound Management

• Implement immediate postoperative prosthesis (IPOP) placement when appropriate, as it allows ambulation on postoperative day 1, reduces revision rates (5.4% vs 27.6%), and decreases time to definitive prosthesis (51 days) compared to traditional soft dressings. 2, 3
• Apply negative pressure wound therapy for complex wounds or those at high risk for dehiscence. 4
• Monitor stump for infection, dehiscence, or skin breakdown requiring daily wound assessment by trained personnel. 2

Pain Management

• Provide multimodal analgesia combining NSAIDs with opioids for high-intensity pain, recognizing that postoperative pain control enhances functional recovery and early mobilization. 1
• Address phantom limb pain through desensitization techniques and appropriate pharmacotherapy. 5

Early Mobilization

• Begin physiotherapy on postoperative day 2 with bed mobility exercises, transfer training, and upper extremity strengthening. 5
• Initiate wheelchair mobility training immediately for patients not receiving IPOP. 5

Subacute Phase (Weeks 1-8)

Pre-Prosthetic Training

• Conduct residual limb strengthening exercises focusing on hip extensors, abductors, and knee flexors. 5
• Implement range of motion exercises to prevent hip and knee flexion contractures. 5
• Perform edema management through compression wrapping or shrinker socks once wound healing permits. 5
• Train in residual limb desensitization techniques to prepare for prosthetic wear. 5

Wound Surveillance

• For major stump complications (operative infection or dehiscence), employ staged operative debridement for source control followed by negative pressure wound therapy and reformalization, which achieves 100% BKA salvage in patients without peripheral arterial disease. 4
• Monitor for wound healing progression with weekly assessments by the wound care team. 4

Medical Optimization

• Achieve glycemic control with HbA1c <7% in diabetic patients to minimize reoperation risk. 6
• Continue antiplatelet therapy (aspirin or clopidogrel) for cardiovascular risk reduction. 6
• Address malnutrition aggressively, as severe malnutrition increases 30-day mortality five-fold. 6
• Screen for and treat depression, which increases mortality by 17% and amputation risk by 13%. 6

Prosthetic Phase (Weeks 8-12+)

Prosthetic Fitting

• Target prosthetic referral within 72 days for optimal functional outcomes, as delays beyond this significantly impair rehabilitation success. 4
• Ensure prosthetic fitting by specialists who understand proper fit and pressure reduction. 6
• Recognize that walking with a prosthesis is the outcome with the greatest impact on quality of life among amputees. 1

Functional Training

• Progress from preparatory to definitive prosthesis with gait training supervised by physical therapists. 5
• Implement balance and proprioception exercises specific to prosthetic use. 5
• Train in activities of daily living with the prosthesis. 5

Long-Term Management (Months 3+)

Contralateral Limb Protection

• Provide customized prescription therapeutic footwear recommended by specialists for the remaining limb. 7, 6
• Conduct annual comprehensive foot evaluations for both the residual limb and contralateral limb. 6
• Implement serial evaluation of foot biomechanics and pressure offloading strategies. 7

Cardiovascular Risk Management

• Continue guideline-directed medical therapy for peripheral artery disease, recognizing that 60-80% of BKA patients have significant coronary artery disease. 6
• Monitor for polyvascular disease progression, which raises all-cause mortality risk by 35%. 6

Rehabilitation Monitoring

• Assess prosthetic use and ambulation status at regular intervals, as 75% of successful BKA patients remain independently ambulatory at 5 years. 3
• Address barriers to prosthetic use, particularly in older patients (>65 years) who face substantial rehabilitation challenges. 6

Critical Pitfalls to Avoid

• Never delay prosthetic referral beyond 72 days, as this significantly impairs functional outcomes. 4
• Do not overlook nutritional status, as malnutrition dramatically increases mortality. 6
• Avoid inadequate glycemic control in diabetic patients before planned procedures. 6
• Never fail to provide specialized footwear for the contralateral limb, as patients remain at high risk for future amputation. 6
• Do not underestimate psychological support needs, as depression significantly worsens outcomes. 6

Special Considerations for High-Risk Patients

For patients with end-stage renal disease, recognize that 5-year survival is only 19%, requiring particularly aggressive multidisciplinary support. 6

For patients with peripheral arterial disease, all stump complications progressing to above-knee amputation occurred in those with PAD, necessitating heightened vigilance. 4

For older patients (>65 years), age independently increases death risk by 4% per year and is associated with lower quality of life outcomes. 6