Functional outcome after prosthetic rehabilitation of children with acquired and congenital lower limb loss

The purpose of this study was to compare the functional status of children with acquired and congenital lower limb loss after 3 weeks and 6 months of prosthetic rehabilitation. Forty-one children aged between 8 and 17 years participated in the study. The children underwent prosthetic fitting, prosthetic training and rehabilitation after physiotherapy evaluations. Gait patterns and weight bearing values were assessed, and the Amputee Mobility Predictor (AMP) Questionnaire was applied. The congenital group had better gait patterns, weight bearing values and AMP scores in the initial assessment and after 3 weeks. The statistical analyses of the same parameters after 6 months showed that there were no significant differences between the two groups (P>0.05). It was determined that all congenital patients and only 16 of 20 acquired patients were wearing their prostheses for more than 8 h a day. When the outcomes of the first assessments were compared, the congenital group showed a better functional level, gait pattern and weight bearing value. At the end of 6 months, an improvement was observed in the functional level, gait pattern and weight bearing value in both the groups. The functional state, gait pattern and weight bearing value of children with limb loss can be improved if they actively use their prosthesis.     

Prosthetic rehabilitation in traumatic upper limb amputees (an Indian perspective)

Introduction Rehabilitation of traumatic upper limb amputees depends on a multitude of factors. This study attempts to evaluate the success of prosthetic rehabilitation in this group of patients, determine the reasons for non-compliance and find ways to increase prosthetic acceptance.Materials and methods The prosthetic rehabilitation status of 71 traumatic upper-limb amputees was assessed by a questionnaire and clinical review. A Prosthetic Rehabilitation Scoring (PRS) system, based on patient satisfaction, prosthetic usage and activity level, was devised to quantify the success of rehabilitation.Results The rehabilitation was found to be equally good in above-elbow and below-elbow amputees. The delay in fitting of the prosthesis had no correlation with successful rehabilitation. Chances of successful rehabilitation decreased when the prosthesis fitting was done in older patients. The main reasons for inadequate use of the prosthesis were repeated mechanical failure and the high cost of repair and replacement.Conclusion In order to achieve an optimum benefit for the patient in a developing country, the prosthesis should be durable, inexpensive and have a low cost of maintenance.     

Rehabilitation of high upper limb amputees after Targeted Muscle Reinnervation

Study DesignThis is a Delphi study based on a scoping literature review.IntroductionTargeted muscle reinnervation (TMR) enables patients with high upper limb amputations to intuitively control a prosthetic arm with up to six independent control signals. Although there is a broad agreement regarding the importance of structured motor learning and prosthetic training after such nerve transfers, to date, no evidence-based protocol for rehabilitation after TMR exists.Purpose of the StudyWe aimed at developing a structured rehabilitation protocol after TMR surgery after major upper limb amputation. The purpose of the protocol is to guide clinicians through the full rehabilitation process, from presurgical patient education to functional prosthetic training.MethodsEuropean clinicians and researchers working in upper limb prosthetic rehabilitation were invited to contribute to a web-based Delphi study. Within the first round, clinical experts were presented a summary of recent literature and were asked to describe the rehabilitation steps based on their own experience and scientific evidence. The second round was used to refine these steps, while the importance of each step was rated within the third round.ResultsExperts agreed on a rehabilitation protocol that consists of 16 steps and starts before surgery. It is based on two overarching principles, namely the necessity of multiprofessional teamwork and a careful selection and education of patients within the rehabilitation team. Among the different steps in therapy, experts rated the training with electromyographic biofeedback as the most important one.DiscussionWithin this study, a first rehabilitation protocol for TMR patients based on a broad experts' consensus and relevant literature could be developed. The detailed steps for rehabilitation start well before surgery and prosthetic fitting, and include relatively novel interventions as motor imagery and biofeedback. Future studies need to further investigate the clinical outcomes and thereby improve therapists’ practice.ConclusionGraded rehabilitation offered by a multiprofessional team is needed to enable individuals with upper limb amputations and TMR to fully benefit from prosthetic reconstruction.Level of EvidenceLow.     

Rehabilitation of burn patients with concomitant limb amputation: case reports

Burn patients with associated limb amputations present demanding rehabilitation problems, many of which might be expected to lead to chronic difficulties. Therapeutic goals following limb amputation include oedema reduction, prevention of contracture (through positioning and range of motion), stump shaping, both pre- and post-prosthetic fitting strengthening exercises of the limb and trunk, and gait training. Some patients present problems that are associated with both the burn injury and the limb amputation that cause concern among the physical therapy staff. Some of these situations include intolerance of the stump to pressure or manipulation due to remaining open wounds or fragility of newly skin grafted areas on the residual limb or delayed gait or functional training due to wounds on other body surface areas. Delays in stump preparation or other treatment aims due to continued surgical procedures can be worrisome. A review of these patients indicates the possible difficulties that rehabilitation personnel may face when treating burn victims who required amputation. Effective rehabilitation of these patients can be achieved despite the noted concerns.     

Major lower extremity amputation in patients with peripheral arterial insufficiency with special reference to the transgenicular amputation

The selection of the proper level for lower extremity amputation in patients with advanced arterial ischemia poses a multiplicity of problems with regard to operative mortality, stump healing, re-amputation rate and rehabilitation status. In a retrospective study all these parameters have been evaluated in 413 patients submitted to below-knee (bk, n = 196), transgenicular (tg, n = 93) and above-knee (ak, n = 124) amputation between 1971 and 1980. As compared to the ak resection, the bk amputation has the following advantages: lower operative mortality (9% vs. 30.5%), higher prosthetic fitting rate (85% vs. 66%) and significantly improved rehabilitation (walking with artificial limb: bk 84%, ak 22%). Regarding surgical mortality (8.5%) and prosthetic gait (66%), the tg amputation was nearly equivalent to the bk resection and turned out to be clearly superior to the ak amputation. As compared to the latter procedure, knee disarticulation and bk amputation had a greater risk of delayed wound healing and re-amputation at a higher level (ak: 13.5 resp. 1%, tg: 22.5 resp. 25%, bk: 35% resp. 16%). The patient with a bk amputation has the best prospect concerning a successful rehabilitation. Whenever the very important knee joint cannot be saved an ak amputation should be avoided in favour of a knee disarticulation.     

Early post-surgical prosthetic limb fitting in dysvascular below-knee amputees with a pre-fabricated temporary limb

Two consecutive series of patients undergoing below-knee amputation for peripheral vascular insufficiency were compared relative to the length of acute-care hospitalization and rehabilitation. The residual limb control group was treated with soft-surgical dressings and non-weight bearing ambulation with referral to the amputee clinic when the residual limb wound was "ready." The residual limb experimental group was treated with rigid plaster (cast) dressings with early post-surgical prosthetic limb fitting and progressive weight bearing ambulation. Acute-care hospitalization following amputation surgery averaged 27.7 days in the control group, and 23.7 days in the treated group. Patients were either re-admitted or transferred to a rehabilitation unit where hospitalization averaged 42.9 days in the control group and 14.1 days in the treated group. This resulted in a cost savings of almost $15,000 per patient based on present hospital fees. The results of this study suggest that early post-surgical prosthetic limb fitting not only hastens recovery amputation, but can be safe and cost effective.     

Proposed practice guidelines for nonoperative anterior cruciate ligament rehabilitation of physically active individuals

Nonoperative management of anterior cruciate ligament (ACL) rupture has not been a successful option for those who participate in high-level physical activity. However, there are instances when patients may want to attempt to return to physically demanding activities with nonoperative rehabilitation for an ACL injury. The purpose of this commentary is to describe guidelines for nonoperative management of physically active individuals with ACL injuries who wish to return to preinjury levels of physical activity. The guidelines are based on the results of 2 clinical studies that improved the overall success of nonoperative management of physically active individuals with ACL ruptures. A decision-making process for selecting appropriate candidates for nonoperative management (rehabilitation candidates) is described. Individuals are classified as rehabilitation candidates if they have no concomitant ligament or mensical damage associated with the ACL injury, have a unilateral ACL injury, and meet all 4 of the following criteria: (1) timed hop test score of 80% or more of the uninjured limb, (2) Knee Outcome Survey Activities of Daily Living Scale score of 80% or more, (3) global rating of knee function of 60% or more, and (4) no more than 1 episode of giving way since the incident injury to the time of testing. Individuals meeting the criteria of a rehabilitation candidate undergo an intensive rehabilitation program before returning to high-level activity. The rehabilitation program consisting of lower extremity muscle strength training, cardiovascular endurance training, agility and sport-specific skill training, and a training program using balance perturbations is described.     

Energy cost during gait in osteosarcoma patients after resection and knee replacement and after above-the-knee amputation

We determined the energy cost during gait by measuring the oxygen consumption of twenty-six patients after treatment for osteosarcoma about the knee. Fourteen had had an en bloc resection of the distal end of the femur and proximal end of the tibia followed by segmental replacement with a custom-made knee prosthesis and twelve had had an above-the-knee amputation followed by fitting with an artificial limb. Comparisons of free-walking velocity, oxygen consumption per meter traveled, and per cent of maximum aerobic capacity used during walking demonstrated that patients with resection and prosthetic knee replacement had a lower energy cost during gait.     

Clinical field follow-up of high density polyethylene (HDPE)-Jaipur prosthetic technology for trans-femoral amputees

The purpose of this study was to examine the outcome of the application of the high density polyethylene (HDPE)-Jaipur prosthetic construction in fitting trans-femoral amputees in a number of projects throughout the developing world. Projects in Honduras, Uganda and India were included. One hundred and fifty eight (158) patients had been provided with the HDPE-Jaipur prosthesis and of these 72 were seen for a clinical and technical follow-up after a median of 32 months. More than half the amputees seen had amputation due to trauma and the remainder due to disease. Fabrication and fitting in the three projects was carried out by individuals who had undertaken a three week training course provided by Bhagwan Mahaveer Viklang Sahayata Samiti limb centre in Jaipur. The individuals involved had limited background training in prosthetics. Craftsmanship and fit were assessed as being poor in 86% of cases. Failure requiring replacement of components was observed in 50% of cases. There was low patient satisfaction (58%) and patient compliance (65%). The outcome was considered unsatisfactory both technically and clinically. This was a reflection of the inadequacies of the prosthetic construction, particularly the knee joint, and the inadequate training of those involved in fitting and fabrication of the devices.     

Verbessert mentales Training das Erlernen der Gehbewegung mit Oberschenkelprothese?

BACKGROUND: Mental training is a method for optimizing movement patterns, which has become well established through its application in high performance sport and is also adopted in therapeutic contexts. The question arises as to whether the process of learning to walk following the fitting of a femoral prosthesis can be enhanced by means of mental training. METHODS: In the framework of a prospective randomized study, healthy subjects (36 students) were required to learn to walk with a femoral prosthesis: the control group (n=18) exclusively with the aid of practical training and the experimental group (n=18) with practical and mental training. Dependent variables were specified as the gait parameters of a computer-supported and an observational gait analysis. RESULTS: In comparison to the control group, the experimental group made significantly faster learning progress in all parameters of the computer-supported and observational gait analysis. CONCLUSIONS: Mental training seems to be an effective gait training method following the fitting of a femoral prosthesis. Transferring this method to rehabilitation, particularly in young patients, would most certainly appear feasible.     

A comparison of traditional prosthetic training versus proprioceptive neuromuscular facilitation resistive gait training with trans-femoral amputees

Reports in the rehabilitation literature suggest that patients with trans-femoral amputation ambulate well after suitable prosthetic treatment. The effects of exercise protocols on function, however, have not been documented in this population. This study was conducted to compare the outcome of traditional and proprioceptive neuromuscular facilitation (PNF) techniques on weight bearing and gait. Fifty unilateral trans-femoral amputees who were attending for their first prosthesis, participated in this study. Amputees were randomly assigned into groups receiving the traditional training or PNF. Traditional treatment was consisted of weight-shifting, balancing, stool-stepping and gait exercises. In the other group the same activities were given by PNF. Amputees were trained 30 minutes daily, for a total of 10 treatments. Pre- and post-training assessment included weight bearing measurements by using two bathroom scales and time-distance characteristics of gait from footprints. A statistically significant difference was found in all parameters within the groups due to pre- and post-training evaluation data (p<0.05), but more obvious improvement was observed in the group who received PNF (p<0.05). The results of the study suggest that the prosthetic training based on proprioceptive feedback was more effective to improve weight bearing and gait when compared with a traditional programme.     

An audit of amputation levels in patients referred for prosthetic rehabilitation

Most lower limb amputations in the United Kingdom (UK) are carried out within general surgical, orthopaedic and plastic surgical units of district hospitals. This study of patients referred for rehabilitation was undertaken to determine the number and specialty interests of surgeons referring amputees, the numbers referred by each and, as one of several possible measures of appropriateness for rehabilitation, the amputation levels in patients referred for the first time to one sub-regional Disablement Services (limb fitting) Centre (DSC) over a 14 month period. Thirty nine surgeons, referred 263 amputees. The majority (61%) of surgeons referred 5 or fewer: a nucleus of 11 vascular surgeons (28%) referred 64% of the patients. The underlying pathology, specialty interest of the surgeon or numbers referred by individual surgeons had no relation to final healed level which was below the knee in 55% of cases compared to national figures for all other DSC's ranging between 39% and 48% below-knee between 1981 and 1988. Since current practice in the UK is to refer all but the frailest patients for consideration of prosthetic rehabilitation, this study suggests that, nationally, more patients could be suited for the functionally superior below-knee level of amputation than are currently benefiting from it.     

A feasibility trial of a prefabricated immediate postoperative prosthetic limb system

In this feasibility trial, 32 consecutive patients undergoing transtibial or knee disarticulation amputation had application of a prefabricated immediate postoperative prosthesis in the operating room following lower extremity amputation. Partial weightbearing was initiated on the first postoperative day. Twenty-nine underwent primary amputation as a consequence of nonsalvageable gangrene or diabetic foot infection. Others were performed at the time of wound closure following traumatic amputation for a crushed extremity and one was performed for an infected nonunion of the tibia and fibula. Seventeen of the 29 patients with diabetes were insulin dependent. Nine patients required renal dialysis and were diagnosed with concurrent malnutrition. Twenty were male and 12 were female, with an average age of 61.6 (range, 42-90) years. The average time to custom prosthetic limb fitting was 8.1 (range, 4-16) weeks. This preliminary experience with a commercially available pneumatic immediate postoperative prosthetic limb system supports its role in the early rehabilitation of lower extremity amputees.     

The value of stump split skin grafting following amputation for trauma in adult upper and lower limb amputees

One hundred and twenty adult patients were reviewed in whom split skin grafts were applied to the stump following traumatic amputation of the upper limb (44 amputees) or lower limb (76 amputees). The average follow-up period was seven and a half years after initial amputation. There was delay in prosthetic fitting in all patients. Approximately one third of patients complained of occasional minor ulceration, controlled by removing the prosthesis for a few days or modification of the prosthesis. Further revision surgery, including excision of the grafted skin often combined with proximal bone resection, but not removal of the proximal joint, was necessary in 29% of below-elbow amputees and approximately 50% of below and above-knee amputees. At the above-elbow level, use of skin grafts allowed prosthetic fitting because of preservation of sufficient length of the stump. Despite the fact that revision surgery may often be necessary, split skin grafting has a definite place in the early management of the stump following traumatic limb amputation in the adult. Preservation of stump length with the knee or elbow joint allows easier rehabilitation and lower energy expenditure when using the prosthesis. Partial foot amputation, when combined with skin grafting usually requires subsequent revision to a more proximal level to obtain a satisfactory result.     

A critical review of amputation in vascular patients

A study was made of 53 patients who underwent amputation for peripheral vascular disease over a 5-year period at West Virginia University Medical Center. The follow-up period ranged from 1 to 6 years. Data concerning operative deaths, risk factors, use of prosthetic devices, and ultimate self-sufficient living were obtained. The functional outcome for this group of patients was encouraging with modern prosthetic fitting and social rehabilitation. Approximately 75% of the patients were returned to a useful life with a prosthetic limb or in a wheelchair. Amputation is a less desirable alternative than successful revascularization, but with the prostheses available today, amputation does not foreshadow a dismal existence.     

Clinical field follow-up of high density polyethylene (HDPE)-Jaipur prosthetic technology for trans-tibial amputees

The purpose of this study was to examine the outcome of the application of the High Density Polyethylene (HDPE)-Jaipur prosthetic construction in fitting trans-tibial amputees in a number of projects in the developing world. Projects in Honduras, Uganda and India were visited. Three hundred and twenty (320) patients had been provided with a HDPE-Jaipur prosthesis and of these 172 were seen for a technical and clinical follow-up after a median of 35 months. More than half the amputations were due to trauma, the remainder to disease. Fabrication and fitting in the three projects was carried out by individuals who had undertaken a twice week training course provided by Bhagwan Mahaveer Viklang Sahayata Samiti limb centre in Jaipur. The individuals involved had limited background training in prosthetics. Craftsmanship and fit were assessed as being poor in 56% of cases. The technical quality of the Jaipur foot was considered acceptable as its performance was better than previously observed results. Although there was patient satisfaction of 85% and compliance of 94% the HDPE-Jaipur trans-tibial system was not considered acceptable as 49% reported walking distances less than 1km and 36% discomfort. The major inadequacy in outcome relates to the use for fabrication and fitting of individuals with inadequate education and training.     

Selection of level for lower limb amputation

Selection of level of lower limb amputation following trauma or in dysvascular patients must be based on experience, and a broad knowledge of the early and late problems following amputation and prosthetic fitting. Successful wound healing is important to achieve, so that the patient can be soon fitted with a prosthesis, and become involved in a rehabilitation program with the emphasis on early return to work and/or the home environment. It is helpful if the surgeon concerned has some knowledge of the advantages and limitations of prosthetic use at the various levels in the lower limb - too much information in the past has been relayed by word of mouth or repeated ad nauseam in orthopaedic textbooks. After trauma, it is usually a young male patient who must cope with limited function, loss of body image, difficult relationships with friends and loved ones leading to changes in their pattern of life and future plans.The dysvascular patient, however, is running ‘out of time’. Stewart²¹ reported a mean survival in peripheral vascular disease patients of only four years plus two months, when compared to the diabetic dysvascular patients of only three years plus eight months, after the amputation. If a patient survives for more than three years, there is a high chance that the other limb will be lost during that period. Young diabetic patients without peripheral vascular disease present with significant problems from peripheral neuropathy, osteoarthropathy of the foot and ankle, retinal damage and kidney problems often requiring long-term dialysis. These patients have limited life expectancy and selection of the level of amputation must take into consideration the necessity for early prosthetic fitting and rehabilitation.Diabetic patients with absent foot pulses should not be treated any differently from non-diabetics when the level of amputation is being considered. Similarly, elderly patients with athero sclerosis should be assumed to be diabetic, and this assumption should be verified by appropriate biochemical tests. Both groups should be intensively investigated in the hope that angioplasty or by-pass procedures may prolong limb survival if only for a limited period. There have been suggestions that the level of amputation and need for revision in dysvascular patients may be affected adversely by prior attempts at revascularization, but other studies fail to support this claim.^22,23Unfortunately, one must be both realistic and pessimistic about prosthetic fitting and use, especially in trans-femoral amputees. In a recent publication,²⁴ the authors conclude that only 10% to 15% of dysvascular amputees achieved mobility around the home on their prosthesis, and only 5% rehabilitate well independent of their wheelchair. They emphasize that when amputation is inevitable, more consideration should be given to surgery that optimizes wheelchair rehabilitation. These findings must make a surgeon responsible for performing the amputation continually aware of the importance of preserving the knee joint in the elderly dysvascular patient.     

Surgical experience and supervision may influence the quality of lower limb amputation

AIM: Only half of those patients undergoing major lower limb amputations for peripheral vascular disease (PVD) are likely to mobilise on a prosthesis. This study aimed to determine whether a surgeon's experience influenced the quality of the residual limb and thus the likelihood of the stump being suitable for a prosthesis. METHODS: All patients undergoing major lower limb amputations for PVD were recruited prospectively, between August 1992 and July 1996. Following surgery, patients were categorised, by a consultant in rehabilitation medicine, as potentially suitable (group 1) or unsuitable (group II) for rehabilitation. Patients in group I were further assessed by prosthetists for limb fitting. RESULTS: A total of 217 patients underwent 260 amputations for PVD between 1992 and 1996: transfemoral (TFA) 131, trans-tibial (TTA) 127, and through-knee (TKA) in 2. The 30-day mortality was 12% (n = 27). Following surgery, 109 patients were assigned to group I (51%), and 81 patients to group II (37%). The proportion of junior surgeons performing surgery was similar for patients in both groups. Twenty-three amputation stumps (9%) required revision or conversion to a higher level within 30 days. Revisions or conversions were significantly more frequent where the original operation had been performed by an unsupervised junior surgeon rather than a senior surgeon (P = 0.009). The rate of defective amputations compromising limb fitting also reached significance when unsupervised junior and senior surgeons were compared (P = 0.04). CONCLUSIONS: Rehabilitation of the relatively few amputees who reach the stage of limb fitting is hindered by poor surgical technique in a large proportion of cases. Patients operated on by a more experienced surgeon had a better chance of mobilising without revision or conversion surgery.     

Prosthetic usage following major lower extremity amputation

There were 157 patients following major lower extremity amputation who were evaluated to determine functional prosthetic ambulation. Twenty-eight patients were evaluated in the amputee clinic and found not to be candidates for prosthetic fitting. Forty-one patients were fit with a prosthesis but did not become functional prosthetic ambulators. Eighty-eight patients became functional prosthetic ambulators. Of all above-the-knee amputees, 46% became functional prosthetic ambulators. Only 19% of bilateral lower extremity amputees became functional prosthetic ambulators. Of all below-the-knee amputees, 66% became functional ambulators. The presence of coronary artery disease decreased the ambulatory potential in above-the-knee or bilateral amputees but not in below-the-knee amputees. A screening method for elderly, dysvascular amputees should be instituted prior to prosthetic fitting.     

Rehabilitation of lower limb amputees and some implications for surgical management.

Aspects of peri-operative management, amputation level and rehabilitation of the lower limb amputee are reported in the context of a review of a rehabilitation service for amputees which includes an integrated prosthetic service. Two hundred admissions were reviewed and some complex cases described. It is concluded that: a very close liaison between the surgeon and the rehabilitation team (ideally with preoperative consultation) is in the patient's best interests; any person previously walking (or a potential walker) should be considered for a trial of prosthetic walking; an integrated prosthetic service enhances the efficiency of the rehabilitation service; and that modification of the current Artificial Limb Scheme to allow manufacture of first definitive limbs in prosthetic rehabilitation units would further enhance service to patients.