Rehabilitation Task Force Technical Note: Amputations and Prosthetics in Gaza

The war in Gaza has resulted in thousands of amputations, including early estimates of over 1000 children, all of whom have immediate and life-long needs.

Surgical amputations performed under extremely difficult conditions are likely to be sub-optimal, meaning many of those amputated will require further surgery. People with amputations also require early and ongoing rehabilitation and access to a long-term prosthetics service. In Gaza, at present, none of this is possible due to damage or destruction of services, premises, displacement and scattering of rehabilitation professionals around Gaza strip and abroad and insecurity.

Pre-existing prosthetics centres in Gaza were located around Gaza city, and are currently not operational:

• The Sheikh Hamad Hospital, established in 2016, was severely damaged in the early stages of the war. It fitted around 150 new prosthetics a year and 250 new orthotics.

• The Artificial Limbs and Polio Centre (ALPC) previously provided services to over 3000 people a year, including 300 new prosthetics and 2300 new orthotics. Though it has not been damaged, it is currently not accessible for staff or patients.

The successful rehabilitation of amputees during war requires a coordinated, multidisciplinary effort that begins now and continues long after the war has ended. Short-term interventions are discouraged. There will be a need for an enormous surge in rehabilitation efforts, and the scale up must be coordinated with the rehabilitation task force.
Wherever possible, support should be prioritised to existing organisations in Gaza with experience in this area.

To ensure the successful rehabilitation of amputees in Gaza, the rehabilitation task force recommends that:

• Surgical teams should include rehabilitation professionals to provide early peri-operative rehabilitation care.

• Surgical facilities should keep records of all those amputated to allow for coordinated follow up.

• Surgical facilities should report on the total number of limb amputations (excluding toes and fingers) and level of amputation performed to allow for estimation of future needs.

• Referral hubs including experienced rehabilitation professionals should be established as soon as the security situation allows. These hubs should include inpatient rehabilitation beds (step-down units) as well as outpatient services.

• Outreach rehabilitation services should be established for patients with difficulty regularly reaching the outpatient service.

• Rehabilitation services should start at the perioperative stage and continue during the pre-prosthetic phases, prosthetic fitting, and training after the delivery of the prosthesis. Provision of relevant assistive technology is recommended throughout the phases.

• Priority should be given to reopening existing prosthetics centres and ensuring access to raw material.

• Coordinated expansion of additional prosthetics services should be undertaken to ensure relevant geographical access for those in need across the Gaza Strip. A surge in the number of P&O specialists and supplies will be required.

• One-off fittings or donating prosthetics should be avoided, as service sustainability is critical. Second-hand prosthetics from abroad should not be donated. Please coordinate with the rehabilitation task force for advice on this subject.

• Medical evacuation for prosthetic provision should be an absolute last resort—only where there is no possibility of provision inside Gaza. In such circumstances, efforts must be made to ensure that any prosthetic fitted can be maintained and re-fitted in Gaza.

• One central, coordinated referral system should be established from surgical to outreach level to ensure a continuous pathway of care and avoid drop-off or duplication of services.