Functional Amputee Program Overview
Our functional amputee program focuses on patients facing amputation and patients experiencing complications of an amputation. Our mission is to give our patients a leg that allows them to function at the level that they desire. Existing complications include bone, soft tissue and or signs of phantom or residual limb pain and neuroma pain.
Bone problems include heterotopic (misplaced) bone formation or misalignment. Soft tissue problems can include excessive tissue, unstable soft tissue, and poorly healed incisions. If the underlying muscles have not been myodesed (stabilized) and the tendons have not been tenodesed (sutured to a bone) to the distal tibia at the time of the original amputation, muscle wasting can occur and could lead to a prominent bone at the distal end of the stump. Not only this, but poor fittings of a prosthetic limb can also lead to an extensive breakdown of skin and tissues creating overall decreased functionality.
A poorly tapered amputation that does not fit easily in a prosthesis is a continual source of problems. The skin envelope must be smooth, free moving, without depressions and tapered. A misplaced bone or formation of an extra bone can create pressure points within the distal stump and if the skin is adherent to the underlying bone, this will always be a source of friction leading to a potential breakdown of the skin and tissue. Nerve problems are primarily associated with phantom limb or neuroma pain.
Phantom limb is a sensation or pain that is felt in a body part that no longer exists. This is due to a complex connection between the nerves, spinal cord, and brain. These sensations are different for every patient and can include shooting pain, cramping or squeezing, numbness, itchiness or extremes of temperature. Some of these symptoms can present mildly, but often they can be debilitating and interfere with activities of daily living.
Neuroma pain is due to the nerves to the leg or foot being cut during the amputation. The cut nerve ends attempt to regenerate by sprouting new nerve fibers, but this disorganized regeneration results in a painful growth at the end of the nerve. Neuromas can be a cause of phantom pain. They can also cause significant pain when wearing a prosthetic leg, which can put pressure on the nerve ends. Neuroma pain is typically burning, tingling, or electrical in quality and radiates down the leg, even to the phantom foot.
Our patient population includes any patient facing amputation or with an amputation. Whether you have lost a limb to diabetes or a devastating trauma, our specialists are here for you. We strive to help our patients transition into a pain-free, functional lifestyle, and to become comfortable in their own skin by treating the whole patient. We use a multidisciplinary team approach to provide our patients with optimal treatment through our high-quality and innovative care techniques.
Our amputee services include our very own Plastic and Reconstructive surgeons, Christopher Attinger, MD, Grant Kleiber, MD, Derek Masden, MD, podiatric surgeon, Tammer Elmarsafi, DPM, and the Medical Director for the Amputee Rehabilitation Program at MedStar NRH – Howard Gilmer, DO.
Learn more about MedStar Health’s amputee services from our MedStar National Rehabilitation Network.
Our Approach to Care
At MedStar Plastic and Reconstructive Surgery, our specialists offer the most advanced treatment options for people who suffer from phantom limb pain, neuromas, or other complications following amputation. Some of these are as follows:
- Foot and ankle reconstructive surgery
- Pain management
- Gait evaluation
- Prosthetic devices and diabetic orthotics
- Total contact casting (TCCs)
- Wound care services
- Physical therapy services
For new amputees, physicians explore the functional outcome that the patient desires to achieve. Your specialist will confer with the prosthetist in the pre-amputation setting. With multidisciplinary action, they can then determine the best leg that will be designed in the operating room to achieve the necessary and proper function for the patient.
The amputation procedure features reattachment of all the muscles so that the leg can function well without shrinking over time. Our specialist can also add a vascularized bone fusion between the tibia and the fibula (ERTL) to diminish torque. Allowing the patient to get back to any sports activities that they enjoy. Finally, our peripheral nerve surgeon uses targeted muscle reinnervation (TMR) to diminishes the risk of perioperative pain as well as prolonged postoperative phantom pain.
Our current data shows the highest ambulatory rate as well as the lowest pain scores published in world literature today. We are constantly perfecting our technique so that your amputation can be later adjusted for newly designed prostheses.
Nerve pain can be treated with non-narcotic medication such as gabapentin or Lyrica (pregabalin). If these treatments are ineffective, many patients respond well to surgical treatment.
When nerves are cut for amputation, the remaining nerve may swell in size as a response to this injury. This can cause the nerve to become entrapped or pinched in the normal anatomic tunnels, as the nerve enlarges it is now too wide for these tunnels. Surgery to open the space around the nerve to relieve these compression points is often effective for pinched nerves.
If nerve pain is caused by a neuroma, it is often helpful to surgically remove the neuroma. The end of the nerve may be buried higher up away from the contact surface of the stump, or better yet connected to a motor nerve to give it a path for regeneration. This is known as Targeted Muscle Reinnervation.
Targeted Muscle Reinnervation (TMR):
In a TMR procedure, the sensory nerves are connected to motor nerves to muscles that are no longer in use. The most common example of this is transferring sensory nerves that used to supply the foot, and connecting these to motor nerves to muscles that used to flex and extend the toes. These muscles are no longer in use after an amputation. This nerve transfer allows the sensory nerve a path for regeneration into the muscle and prevents neuroma formation. Patients who undergo TMR procedures have approximately 50% reduction in phantom pain and residual limb pain compared to patients who do not have TMR procedures. MedStar Georgetown is one of the highest volume TMR centers in the world, performing over 100 TMR procedures per year.
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Frequently Asked Questions
You may be a good candidate if:
In most cases, our consultations regarding pain or complications resulting from amputation are covered by insurance. However, it’s always best to discuss coverage questions with your insurance carrier before your consultation.
If you’re exploring options for insurance coverage, you may need to request a referral from your primary care doctor, depending on your health insurance plan. Check with your carrier to see if medical coverage is an option for you and, if so, whether a referral is required.
We strive to help our patients transition into a pain-free lifestyle and to become comfortable in their own skin by treating the whole patient. We want to make sure that you can attain the highest level of function given your physiologic and mental capacity. With our multidisciplinary team approach, we provide our patients with optimal treatment through our high-quality and innovative techniques of care
Before surgery, you may be asked to get cleared by your Primary Care or another specialty provider. You may be asked to undergo lab and other testing, and to take or hold your medications. If you smoke, quitting will help you heal faster and avoid complications. If you are diabetic and are facing elective surgery, your hemoglobin A1C should be below 8. If the situation is emergent, we will manage your glucose levels to optimize the outcome.
You’ll also need to arrange for transportation to and from the surgery and for someone to stay with you the night after the surgery.