About IMPARTS


Integrating Mental & Physical Healthcare: Research, Training & Services (IMPARTS) is an initiative funded by King’s Health Partners (KHP) to integrate mental and physical healthcare in research, training and clinical services at Guy’s, St Thomas’ and King’s College Hospitals, as well as South London and Maudesley NHS Foundation Trust.

The overall goal of IMPARTS is to improve mental healthcare provision within the medical settings across KHP.

The IMPARTS package for physical healthcare setting is designed to support clinical teams in providing timely, tailored, evidence-based care to patients presenting at King’s Healthcare Partners’ acute trusts.

The package has five components:

  1. An informatics system that facilitates routine collection of patient-reported outcomes, with real-time feedback to guide clinical care.
  2. Development of mental health care pathways for patients identified via the informatics system.
  3. Training in core mental health skills for physical healthcare teams, alongside ongoing support and supervision from a mental healthcare specialist.
  4. A portfolio of bespoke self-help materials tailored to specific patient groups.
  5. A research database to facilitate research through the routine collection of patient reported outcomes in a medical setting.

An introduction to IMPARTS video

Fiona’s Story

For more information on IMPARTS, please click here.

How it works


All patients in the the Limb Reconstruction Unit are given a short psychological and physical assessment questionnaire on an iPad, to be completed whilst in the waiting room.
The results of this are fed in real time to the Electronic Patient Register (EPR), allowing the consultant during the appointment to discuss any concerns or issues, and to be able to refer the patient for further support as required.

Help sheets


Please click each title or image to view or download the help sheets:

Learning to Control Your Anger
Ideas for managing your anger after limb reconstruction

Are you on Edge?
Coping with the stress and worries of limb reconstruction

Coping and Living Well
Ideas for managing your feelings after limb reconstruction

Are You Struggling?
Depression and living with the effects of limb reconstruction

Keeping Active
Planning how to spend your time

Getting on With Life After a Trauma
Coping with limb reconstruction after an accident

Physiotherapy

Stay motivated



Physiotherapy plays an important role throughout limb reconstruction treatment. Your physiotherapist will guide you through the process and you must make sure you complete your physiotherapy each day. You will have times when you find it difficult to stay motivated. Speak to your physiotherapist about this as regularly changing your exercises to maintain some variety can be helpful.

You can also complete your physiotherapy in different environments – at home, in the gym or at the hydrotherapy pool. Patients are only allowed in the hydro pool if their pin sites are not weeping or infected: you consultant will advise you whether or not you can exercise in the water. Involving your family and friends can also provide you with support.

You can read more about physiotherapy on the website of The Chartered Society of Physiotherapy.

Why it’s important



You will see a physiotherapist initially whilst you are in hospital, and will then be referred to your local hospital to continue physiotherapy as an out-patient. You will continue physiotherapy after your frame has been removed, to make sure you recover and achieve your full potential.

Physiotherapy can help prevent a number of common problems that can occur in patients undergoing limb reconstruction. Your physiotherapist will assess your joints. muscles and tendons and show you exercises designed to work on any problems they observe. These exercises may aim to increase the strength in weak muscles, stretch tight muscles and tendons, or move joints through their full range of movement.

Solving problems
Patients with a lower leg frame tend to have specific problems with their foot, so this may be an area on which you need to concentrate. You may have to wear splints to keep you arm or leg in a good position while you are resting. You will also be advised how to rest, for example keeping your arm or leg elevated to control swelling. Swelling can also be managed by massage which your physiotherapist can teach you.

Once your consultant is happy for you to do so, taking weight through your arm or leg is very important. It stretches muscles and tendons and stimulates healing. Patients with a leg frame often find this difficult and tend to walk with a limp. Your physiotherapist will works with you to improve your mobility and to make sure you have a good walking pattern.

A limb reconstruction frame can affect your balance reactions, also known as proprioception. This is another area of rehabilitation that you will have to work on and your physiotherapist will give you exercises to do at home. Throughout the limb reconstruction process you should use your arm or leg as normally as possible, and your physiotherapist will advise you on how you can be as independent as possible.

Our own physiotherapist



One of the first things Rebuild did was to ask our patients how we could help more. Many people said that they needed better access to physiotherapy. We consequently raised the funds and developed our own specialist physiotherapy service as part of the clinics.

Part of our physiotherapist’s role is to educate other physiotherapists to work in the fairly specialist field of limb reconstruction.

You can read more about physiotherapy on the website of The Chartered Society of Physiotherapy.

Help sheets


Help sheets giving physiotherapy advice for patients and physiotherapists, for downloading or printing.

For patients:
Physiotherapy advice for patients having limb reconstruction
A help sheet giving essential physiotherapy advice for patients, such as how to relieve muscle tightness, joint stiffness, swelling and a host of other suggestions and recommendations for patients. For patients at KCH, you will also find contact details for the senior physiotherapist in limb reconstruction, as well as the clinical nurse specialists.

For physiotherapists:
Guidance for Physiotherapy management of patients with fractures stabilized by a circular ring fixator

Pain Management

Pain Relief


What will happen after the operation?

Pain relief
You should discuss post-operative pain relief with your anaethesist before the surgery. You may have a PCA (Patient-Controlled Analgesia) device. This allows you to receive strong painkiller directly into the circulation via a pump whenever you require it, simply by pressing a button. You cannot receive too much because the device will be limited by the anaesthetist to a dose which is safe for you. Your surgeon will also put some long-acting local anaesthetic into the wound if this is appropriate. Local anaesthetic catheters (fine tubes) can be useful for reducing the pain from smaller operative sites and you should discuss this with your surgeon. These can be left in for a day or two

What type of drugs are used?
Some procedures are relatively painless and will require only simple analgesia such as Codydramol or Cocodramol (paracetamol and a weak opiate such as morphine type drugs).

We can add in anti-inflammatories such as Ibuprofen (Brufen or Nurofen) or Diclofenac Sodium (Voltarol), but we are keen to avoid these in limb reconstruction since they delay bone healing.

In more major procedures, we will use stronger drugs such as OxyContin, Tramadol, Morphine or Diamorphine. These can have the disadvantage of making some patients feel off their food or nauseous, delirious or sleepy. They can also cause constipation and breathing problems. So we do try to tail these off as soon as possible.

Spinal anaesthetics (epidural) are injections info the spine to make you numb from the waist down. They normally last for two hours. If your operation will take less time, it may be appropriate for the operation period, but it is not usually used for post-operative relief.

An epidural catheter (fine tube) can be inserted around the nerves leaving the spine and left in for a few days, in a similar procedure to the spinal anaesthetic. We try to avoid these in limb reconstruction, because there is a risk that the signs of compartment syndrome could be covered up by the total numbness that results from epidurals. Compartment syndrome is a rare build up of pressure in the leg or forearm that needs to be released immediately. It is only detectable by rising levels of pain.

Further help
While you are in hospital you will have regular visits from the pain teams who will monitor your pain and advise on the particular combination of drugs to manage your pain levels. You will also be sent home with a prescription of your combination of pain relief. Make sure you have the contact details of who you should call if you find are not able to manage your pain when you get home. In an emergency go to your nearest accident and emergency department.

FAQ About Pain Relief


Will I have pain after my operation?
Yes, unfortunately limb reconstruction surgery is accompanied by pain post-operatively, but there are many available methods of pain relief which you can discuss with your anaesthetist and the pain team.

How can the pain be relieved immediately after my operation?
Post-operative pain relief is tailored to individual patient needs. This can be a combination of different methods that include a PCA, local anaesthetic infiltration or regular opiate-based analgesia orally.

Are there any alternatives to morphine?
Yes, there are other equally strong pain killers such as oxycodone or fentanyl. There are given either into a vein (intravenous) or under the skin (subcutaneous).

Are there any dangers associated with morphine?
Morphine can cause you to become drowsy and your breathing to slow down and become more shallow if you have too much of it. The nurse will check this at regular intervals.

Can I overdose myself with a PCA?
No. If you are using a PCA machine and you become drowsy you will not press the button on the machine. The machine is set to deliver small doses at 10 minute intervals, so you will not overdose yourself. This is called the ‘lock-out’ period. It is most important that you and only you press the button to activate the PCA.

Can I become addicted to morphine?
You should use morphine for as short a time as possible. You will not become addicted to it in a few days. If you need it for longer than 2 weeks you can become tolerant (need more and more to have the same effects) or dependent (withdrawal symptoms such as shivering, shaking and nausea when it is stopped). The pain team nurses and doctors will come and advise you about other pain relieving drugs if your pain is persistent.

Will my pain last for a long time?
This is very variable but, because of the pins and frame, there tends to be pain and discomfort for several weeks.

What can be done to help persistent pain and discomfort?
Less strong pain relieving drugs are used, such as codeine and Tramadol. If these are not strong enough for you a slow acting morphine table taken twice a day by mouth can be used, or a drug called buprenorphine can be given as a skin patch. Paracetamol is safe and this is continued for as long as you need it.
Other drugs, such as Gabapentin and Amitriptyline, are often used for nerve pain.

Can anti-inflammatory drugs such as Ibuprofen (Brufen, Nurofen) and Diclofenac (Voltarol) be used?
No. This group of pain killers is not recommended as there is evidence as they can delay bone healing.

What are the side effects of painkillers?

  • Nausea, occasionally vomiting (being sick)
  • Drowsiness
  • Constipation (you may need laxatives)
  • Itching all over the body (without a rash)
  • Difficulty in passing urine (especially if you have a prostrate problem)
  • Dizziness
  • Mood changes
  • Sweating
  • Headache (Tramadol)

These side effects may pass or you may need to try a different pain killer.

About Opioids


Long term side effects of morphine and other strong opioids

Drugs like morphine are call opioids. All these drugs lower the hormones in your body after months of use, especially testosterone in men and oestrogens in women. This could have an adverse effect on your bone density which will affect healing, so these drugs should be used for as short a time as possible. Hormone levels should be checked if you are on morphine or similar for several months.

Codeine
Codeine is changed in your liver to morphine, so if you take it in large doses, for example co-codamol 30.500, which contains 30mg codeine and 500mg paracetamol per tablet, it has the same short and long term side effects as morphine, and is very constipating.

Tramadol
Tramadol is classified as a strong opioid analgesic. It has a dual effect, which means that it works partly in the same way as morphine, but also through other chemicals in the nervous system. It can be addictive in some people.
It is best to take all your pain killers in the lowest dose possible and for as short a time as possible, but you should not be afraid to take them as needed immediately after surgery.

Other drugs
Trauma, surgery and the application of limb frames may stretch or damage fine nerves and give rise to nerve pain, called neuropathic pain. This is associated with a burning, stinging feeling on the skin, or sharp stabbing pains which come at any time. There may be numbness, pins and needles or increased sensitivity of the skin to touch, to hot or to cold. This is a normal part of the healing process, but does take weeks or months to settle. The pain team doctors will advise you about drugs, such as Gabapentin, Pregabalin and/or Amitrypyline, which are used for treating nerve pain. Local anaesthetic skin patches, called Versatis, can sometimes be used on areas of sensitive skin or around the pins.

Physiotherapy and Pain


Physiotherapy can help in reducing your pain after your operation and during the treatment period. Exercise and movement within your pain-controlled limits and as recommended by your Physiotherapist or Consultant are important to help prevent problems from occurring.

The common problems that physiotherapy can help with are:

  • Muscle contractures and tightness
  • Joint stiffness
  • Muscle weakness
  • Swelling
  • Poor mobility and walking pattern

If you are taking painkillers make sure you give them enough time to take effect before doing your exercises.

You will be able to move more easily if you pain is well-controlled.

Can I relieve pain without drugs?
Keeping occupied, moving as much as possible, socialising and being with family and friends all help you to cope with the pain. Acupuncture may be helpful but is not recommended until healing of the skin has taken place.

Psychological support


Anxiety increases pain. If you have worries, talk them through with someone.

Depression increases pain, so if you feel you are becoming depressed it’s important to talk about your feelings. As a result of research through the King’s College Hospital IMPARTS (Integrated Mental and Physical Healthcare Research Training and Services) programme, the Limb Reconstruction Unit at KCH has had its long held view confirmed: patients undergoing limb reconstruction surgery have a real need for access to psychological counselling. Rebuild has therefore paid for the development of a patient psychological support service with the assistance of the Consultant Psychiatrist, Matthew Hotopft of the Maudsley Hospital.

Alternatively, if you prefer, a referral can be made by your consultant to your GP.

Coping with a Frame

Removing a frame


These videos show the process of frame removal.

The struts are dynamised to see if the leg is strong enough to bear weight:

Dynamisation of Struts

The patient walks on a dynamised frame to check that the bone is strong enough for the final removal of the frame.

Walking on Dynamised Frame

The rings are removed.

Taking Rings Off

Once the rings are removed, the pin sites will bleed for a few hours. Dressings are applied, with instructions to remove after 48 hours.

Dressing The Pin Sites

With thanks to Mark Phillips, consultant orthopaedic surgeon and founder Chair and former trustee of KLRT, nurse Debbie Bond, and patient John for nobly sharing his experience

Dressing the pin sites


All patients are taught how to look after pin sites before leaving hospital. Pin sites need to be cleaned to keep them free from infection and to stop them from weeping. Pin sites will weep for a while after surgery, but the aim of good pin site care is to stop them weeping as quickly as possible.

Different methods

There has been much debate about the best way to look after pin sites and many scientific articles have been written on the subject. In reality, there is little evidence to say that one system is better than another. Some departments and surgeons say the pin sites should be covered daily and kept dry. There is also a debate as to whether the scabs should be removed. Other surgeons feel that clean, dry pin sites can be left open to the air. Most surgeons do agree that a daily shower helps. This includes dousing the frame liberally with water. But whether you should use suds or not remains a subject for debate.

This conflicting information can be confusing for patients who may even get different instructions by the professionals who care for them. The main thing is to remember that there are many different approaches, and you should follow the routine that your surgeon recommends for you.

Limb Reconstruction Nurse, Debbie Bond, explains the KCH technique for pin site care to a patient in a Taylor Spatial Frame in this video:

Pin Site Care

What if things go wrong?


Pins going through muscle tend to cause more problems than those going directly into bone. Particularly troublesome pins sometimes have to be removed. Others can be removed after they have done their work in the initial phase of the treatment.

If a pin area becomes increasingly painful, it is usually an indication that it has become infected. At KCH all patients are issued with a prescription of antibiotics to take if a pin site becomes infected.

If you are a KCH patient and think you have an infection you should call the Limb Reconstruction Nurse for advice, and take the antibiotics. If appropriate, you will also be given an appointment in the next weekly clinic.
If the infection is severe, patients are admitted to hospital for intravenous antibiotics (via a drip) and, rarely, to change the pin.

If you are not a KCH patient, you should contact your own medical team for advice.

Adjusting struts


KCH Limb Reconstruction Unit Nurse Debbie Bond explains the process for the adjustment of struts on a Taylor Spatial Frame in these videos:

Limb Reconstruction: Strut Adjustments

Strut Adjustment Detail

When struts in the frame become too long or short, they are changed for the next size. Nurse Debbie Bond talks through the process in this video:

Changing a Strut


This website has information for anyone considering, or going through, limb reconstruction surgery. However we cannot provide opinions on treatment. If you require more information but are not a patient of King’s College Hospital, you should contact your own medical team for advice.