Bilateral below-knee amputations: experience with 80 patients

This review expands information concerning the bilateral below-knee (BK) amputee, describing the findings of a retrospective assessment of 80 such patients. Factors evaluated included etiology, associated conditions, time between amputations, late revisions, use of prostheses, and survival. In 63 patients both amputations were because of atherosclerosis. Of these patients, 86% were diabetic and 84% hypertensive. Peak incidence of the second amputation was during the 7th decade. Average time between amputations was 23 months. Forty-five (71%) of the atherosclerotic patients achieved some functional use of bilateral prostheses. The five patients employed at the time of the second amputation returned to work using prostheses. Average survival after the second amputation was 44 months for those deceased, and 64 months for those alive at the end of the study period. Nine patients had amputations because of various forms of injury, including one for sequential developments due to alcohol-related sensory loss. Eight of this group had a diagnosis of alcohol abuse of psychosis. Reasons for amputations included frostbite, burns, suicide attempt and sensory loss. Five achieved long-term but generally suboptimal prostheses use. The findings support the impression that most atherosclerotic bilateral BK amputees can use prostheses and that their survival and low rate of late stump revisions justify restorative efforts. Mental status was the major determinant of amputation and prostheses use among the non-atherosclerotic patients; discharge from psychiatric hospitals without adequate community support systems was probably contributory. Management and prevention require close collaboration between the rehabilitation, surgical, psychosocial, and public health disciplines.     

Prosthetic use in elderly patients with dysvascular above-knee and through-knee amputations

Fifty-five patients with vascular insufficiency resulting in above-knee (AK) and through-knee (TK) amputations were studied to determine factors related to prosthetic candidacy and functional outcome. Chart review showed that the only difference between patients who were fitted with prostheses and those who were not fitted with prostheses was their respective number of medical complications. Twenty-three of 31 patients with prostheses were evaluated 7 to 35 months after receiving the prostheses. Ten (44%) of these patients wore their prostheses all day every day and used wheelchairs minimally or not at all. Over half of the patients evaluated used their wheelchairs most of the time. Two (9%) of the 23 patients had stopped wearing their prostheses. Patients who demonstrated increased walking distances and velocities at follow-up used their prostheses more and their wheelchairs less than did the other patients. Neither gait factors nor hip range of motion at discharge was predictive of continued prosthetic use. Functional outcome and prosthetic use were limited in this group of elderly patients with dysvascular AK and TK amputations. The results of this study may serve as a basis for clinical determination of prosthetic candidacy and functional goals.     

Prosthetic rehabilitation in bilateral high above elbow amputation

Rehabilitation in patients with bilateral high above elbow amputation presents a considerable prosthetic problem. A patient with high upper arm amputations after a high-voltage injury is presented. He was successfully fitted with multifunctional myoelectric hand prostheses. The problems in rehabilitation of adult bilateral arm amputees are discussed and the value of fitting these patients with electrically powered prostheses is assessed. The balance between technical and clinical aspects is discussed in relation to patient acceptance. In our case good acceptance and functional benefit was noted. The fact is stressed that the bilateral upper extremity amputee can regain considerable physical function with the fitting of suitable prostheses, even if the limb remnants are short and provide little or no function. An extensive team approach at specialized centres will favour the results.     

Gait analysis in amputees

There are marked differences from normal in both AK and BK gait. Forward velocity of walking is significantly lower in the amputee and is lower in the AK than in the BK subjects. Traumatic AK amputees ambulate with time-distance parameters of velocity, cadence, stride length and gait cycle which are all two standard deviations below normal. The same parameters for the traumatic BK amputee are only one standard deviation below normal. The symmetry of walking seen in the normal subject is not present in the lower extremity amputee. Measurements of single limb support times and motion analysis of the lower extremities as well as of the head, arms and trunk bear this out. This asymmetry of motion increases the excursion of the center of mass during each cycle and thereby increases the energy cost of ambulation. Energy cost of amputee gait often places the dysvascular AK amputee at his limits and strains other amputees severely. Further research is necessary to enable amputees to approach the walking capabilities of normal people.     

Prostheses and the forward reach of sitting lower-limb amputees

The hypothesis that prostheses improve the forward reach of sitting lower-limb amputees was tested. While sitting with only ischial support, ten unilateral below-knee (BK) amputees could reach farther when they wore their prostheses than when they did not, when reaching at 45 degrees toward or away from the side of the amputation, with mean differences (+/- 1 SD) of 10.7cm (+/- 6.9, p less than 0.0001) and 4.4cm (+/- 4.1, p less than 0.01), respectively. With ten unilateral above-knee (AK) amputees, the differences were not statistically significant. Seven bilateral amputees (mixed levels) were able to reach farther with their prostheses on than off, with mean differences of 41.2cm (+/- 9.5) and 31.5cm (+/- 7.9) for reaches at 0 degrees and 45 degrees, respectively (p less than 0.0001). With the prostheses off, their reach was significantly greater when their thighs were supported than when they were sitting with only ischial support. These findings suggest that (1) prostheses improve the anterolateral reach of unilateral BK amputees, and the straight forward and anterolateral reach of bilateral amputees; (2) when prostheses are not being worn, a sitting surface which provides support through the residual limbs improves forward reach; and (3) the design of AK prostheses should reflect the patient's needs, both standing and sitting.     

Amputation: energy cost of ambulation.

A mobile instrument system was used to measure energy consumption by indirect calorimetry at rest and during ambulation in 25 unimpaired subjects, 6 unilateral below-knee (BK) amputee patients, 6 unilateral above-knee (AK) amputee patients and 4 bilateral AK amputee patients. To prevent the introduction of gait difficulties among the impaired subjects, each subject was permitted to walk at his own comfortable speed. Since speed thus varied among subjects, ambulation data were expressed in units of energy per foot traveled. Statistical analyses of the mean oxygen costs indicated several significant differences among the groups. In comparison to unimpaired subjects, the mean oxygen consumption was 9% higher in unilateral BK amputee patients, 49% higher in unilateral AK amputee patients and 280% higher in bilateral AK amputee patients.     

Outcome of prosthetic management of bilateral lower-limb amputees.

This study was designed to evaluate the outcome in 41 bilateral lower-limb amputees admitted to an inpatient unit for prosthetic rehabilitation. Outcome measures were obtained using a simple activities of daily living score, the Frenchay Activities Index, mobility grading, and assessment of home adaptations. Though excellent success rates were obtained after completion of physiotherapy, the majority of the above-knee amputees had abandoned their prostheses by the time of review. Bilateral below-knee amputees, however, continued to do well regarding their prosthetic mobility, and prosthesis users were more independent in their activities of daily living. We believe that inpatient rehabilitation programmes for bilateral amputees are likely to prove more satisfactory than prolonged outpatient physiotherapy.     

Oxygen consumption and cardiac response of short-leg and long-leg prosthetic ambulation in a patient with bilateral above-knee amputation: comparisons with able-bodied men

This study measured oxygen uptake (VO2), minute ventilation (VE), and heart rate (HR) in a bilateral above-knee (AK) amputee and in three able-bodied controls during progressive treadmill exercise. Walking conditions for the amputee included using bilateral short-leg (SL) and long-leg (LL) prostheses. A progressive treadmill protocol to maximal capacity was used for the amputee and duplicated by the control subjects. An automated system was used to measure VO2, VE, and HR throughout exercise. Data analysis was restricted to the use of parameter averages and percentages to describe differences between experimental conditions. Maximal VO2 for the amputee averaged 23.3mL/kg-1/min-1 with the LL and 22.8mL/kg-1/min-1 with the SL prostheses, a negligible difference between conditions; however, exercise duration was 27% longer when using the SL prostheses. In addition, when averaged over the first four stages of exercise, VO2, VE, and HR were 24%, 32%, and 14% higher, respectively, when the LL prostheses were used. Treadmill walking by unimpaired controls averaged 47% and 79% more economical than walking with the SL or LL prostheses, respectively. These results demonstrate that the use of currently available AK prostheses requires significant energy expenditure, which limits their use to only the most physically fit individuals.     

Silicone soft socket system: its effect on the rehabilitation of geriatric patients with transfemoral amputations.

OBJECTIVE: To report the effect of supplying new transfemoral amputee patients with a prosthesis with a silicone suspension/interface system. PATIENTS AND DESIGN: Fifty-eight new transfemoral amputee patients were supplied with a contoured adducted trochanteric-controlled alignment method (CAT-CAM) socket (CCS) with a silicone suspension/interface system. This system is called the Icelandic roll-on silicone socket, or the ICEROSS system (IRS). A second group of 18 new amputee patients were supplied with an unlined CCS (uCCS), ie, without silicone sleeve suspension. MEASURES: The IRS group was followed up at 1 year, the uCCS group at 9 months. Ambulatory capacity was investigated by first categorizing patients' prosthetic mobility into four different groups based on the distances patients were able to ambulate: 0 m (wheelchair ambulation only), <100 m, 100 to 500 m, and >500 m. The change in distance ambulated was then determined for each group for the three time intervals between admission, discharge, and follow-up. RESULTS: Between discharge and follow-up patients with the IRS had a significantly greater improvement (p<.001) in distance traversed than patients supplied with the uCCS. Distance traversed had been longer in the uCCS group before they were supplied with the prostheses (p<.05). Inpatient stay in the rehabilitation center was 5 days less in the group supplied with IRS (p<.05). Adjustments to the new socket had to be carried out for 67% of the uCCS group during the observation period, compared with only 21% for those using the IRS system. Satisfaction, average duration of daily use, and the use of assistive devices for gait did not differ significantly. CONCLUSIONS: New patients with transfemoral amputations fitted with a silicone suction socket showed greater gains in distances ambulated, and adjustments to their prostheses were significantly fewer. Therefore, it is preferable to provide these sockets to geriatric amputee patients rather than CAT-CAM sockets without silicone suspension sleeves.     

Evaluation of rehabilitated bilateral lower limb amputees – an Indian study

Objective: This study assessed activities of daily living (ADL) and ambulation of rehabilitated bilateral lower limb amputees with relation to their level of amputation in an Indian setting. Subjects and Methods: This retrospective study of 25 subjects comprised 12 bilateral Trans-femoral (TF) amputees, 8 bilateral Trans-tibial (TT) amputees and 5 a combination of ipsilateral Trans-femoral and contralateral Trans-tibial amputation. All subjects were contacted by post/telephone, were physically examined and assessed at the Orthopaedic clinic at a mean follow-up of 6.6 years. Physical rehabilitation was evaluated using ADL score and by grading the level of ambulation. Results: ADL scores showed no significant difference according to level of amputation (p > 0.05), but the scores of prosthetic users were significantly higher than non-prosthetic users (p?=?0.002). Only 11/25 amputees became prosthetic ambulators and most (50%, 6/12) were TF amputees. All prosthetically rehabilitated subjects were mobilising with their prostheses at follow-up and graded as unlimited or limited community ambulators. Conclusion: Though it is well documented that the potential for successful rehabilitation is best for bilateral TT amputees, given the subjects’ economic constraints, higher prosthesis rehabilitation among bilateral TF amputees indicates that successful rehabilitation is possible in most subjects irrespective of the level of amputation.

Implications for Rehabilitation

• Rehabilitation of a bilateral lower limb amputee requires a team effort and constitutes a very difficult challenge for the subject.

• Low prosthesis ownership is largely due to subjects’ inability to afford a pair of prostheses in a developing country like India.

• Activities of daily living improve significantly with use of prostheses.

• Though it is well documented that the potential for successful rehabilitation is best for a bilateral TT amputee, higher prosthesis rehabilitation among bilateral TF subjects in this study indicates that successful rehabilitation is possible in most subjects irrespective of the level of amputation.

     

Inpatient rehabilitation challenges in a quadrimembral amputee after bilateral hand transplantation

Bilateral forearm and hand transplantation poses unique challenges especially in the setting of bilateral lower limb amputations. A 57-yr-old man with bilateral transradial amputations and bilateral transtibial amputations after remote streptococcal sepsis was admitted for inpatient rehabilitation because of severe debilitation after forearm/hand transplantations. He required 6 wks of bed rest to allow the healing of the allografts but developed profound deconditioning. Because of weight-bearing precautions and other complications such as femoral neurapraxia, he required the use of body weight-support apparatus to ambulate with lower limb prostheses, keeping weight off the allografts. He progressed to walking 600 ft using a platform-wheeled walker at a modified independent level, to climbing four stairs with minimal assistance, and to being able to toss a small football using his right hand, indicating improved flexor function in this hand. Tacrolimus levels were maintained without clinical evidence of acute rejection. Through an individualized therapy regimen, careful monitoring of the allografts and dedicated support staff, rehabilitation training of a previous quadrimembral amputee after bilateral hand transplantations can be successful.     

Prevalence and aetiology of amputation in Kolkata,India: A retrospective analysis

This study is an epidemiological report of the medical records of amputees in Kolkata, West Bengal, India. This retrospective study included 155 amputees who had undergone an amputee physiotherapy rehabilitation program and prosthetic training at the National Institute for the Orthopaedically Handicapped in Kolkata, West Bengal, from January 2008 to January 2010. The paper reports on the prevalence, aetiology, and levels of amputation. The causes of amputation classified under vascular diseases, trauma, and carcinoma are discussed. The most common cause of amputation was trauma (70.3%), the second most common cause being peripheral vascular disease. Lower limb amputation, more common than amputation at the upper limb, accounted for 94.8% of all amputations.     

Bone overgrowth in the adult traumatic amputee

Bone overgrowth of the residual limb after an amputation is a well documented complication in the pediatric amputee population. Bone overgrowth can cause pain, problems with skin breakdown, and poor prosthetic fit. There have been few reports of bone overgrowth in the adult amputee. Two cases of traumatic transfemoral amputations after extensive tissue damage are presented. Both patients successfully completed an in-patient amputee rehabilitation program and achieved functional ambulation with their prostheses. However, each developed distal residual limb pain within a year after their amputations that significantly limited the amount of time they could wear their prostheses and the distance they could walk. Radiographs demonstrated additional bone growth from the residual femur into adjacent soft tissues in both patients. These case examples demonstrate that bone overgrowth should be considered in the differential diagnosis of residual limb pain in the adult amputee.     

Oxygen consumption of elderly persons with bilateral below knee amputations: ambulation vs wheelchair propulsion

Elderly bilateral below knee (BK) amputees were tested for oxygen consumption (VO2), heart rate (HR) and velocity (V) during ambulation on a 40m walkway and a stationary wheelchair ergometer. Values obtained from amputees were compared to values obtained from a control population of the same age group. On test day 1 bilateral amputees and normal subjects ambulated at their natural pace on a walkway for approximately 5 minutes. On test day 2 each subject propelled a stationary wheelchair ergometer at their natural rate for the same distance that they ambulated. Measurements of VO2 (ml/m/kg), HR (beats/min), and V (m/min) were obtained during both sessions. Results show that the bilateral BK group required significantly more VO2 (ml/m/kg) (123%), had higher HR (26%), and slower V (36%) than the normal group during ambulation. The energy cost in terms of ml/min/kg during ambulation was similar, suggesting that the amputees ambulated at the same power cost as normals but at lower velocities. During wheelchair propulsion the BK group and normal group showed no significant difference in the 2 criteria. Results suggest that wheelchair propulsion is a more energy efficient mode of mobility for elderly bilateral BK amputees than ambulation. Energy cost and heart rate determinations may be valuable in choosing the course of mobility training and recommended activity levels. Cosmetic, psychosocial, and other clinical factors must be considered in prescribing rehabilitation.     

Rehabilitation of patients with end-stage renal failure after lower extremity amputation

Four patients with end-stage renal failure on maintenance hemodialysis and one patient with near end-stage renal failure received inpatient rehabilitation following lower extremity amputation. All were prosthetically restored. Three of the patients had bilateral below-knee amputations and were ambulatory at the time of discharge, including the patient with near end-stage renal failure who was on maintenance hemodialysis at follow-up. One unilateral below-knee amputee was also ambulatory at discharge. The other unilateral below-knee amputee had an ulcer on the other foot and used a pylon for transfers only. To assess the prevalence of patients on maintenance hemodialysis with lower extremity amputations, a survey of 310 patients at four dialysis units was performed. Of the 310 patients 2.9 percent had at least one amputated lower extremity and 1.0 percent had bilateral lower extremity amputations. Preliminary data and the potential for functional results following prosthetic restoration suggest the need for further research concerning prosthetic restoration in the lower extremity amputee with end-stage renal failure.     

The initiation of gait in lower limb amputees: some related data

The initiation of gait, from balanced standing position to the toe-off of the stance leg, was analyzed in 8 unilateral above-knee (AK) and 10 unilateral below-knee (BK) males amputees. Thirty-one parameters were measured, including ground-foot forces and the movements and timing of hip, knee, and ankle joints. The significant changes from the normal pattern of initiation of gait found in the AK and BK amputees, as well as significant changes between the two amputees groups themselves, are described. The amputees were divided into two subgroups: those who start walking with their prosthesis and those starting with their normal leg. The two groups were compared statistically for each amputation level and all were compared to a normal subjects group. Differences relating to the choice of the swing leg were found. The findings are reported as part of a future databank.     

Suction socket suspension for below-knee amputees

In this study the current use of suction suspension for below-knee prostheses is examined by means of two questionnaire surveys. The experience of 56 below-knee (B-K) amputees wearing suction socket prostheses is evaluated comparing suction prostheses with previously worn limbs. A high degree of satisfaction was found, with amputees on the whole reporting improved skin condition, diminished pain, and increased activity levels compared to previous prosthetic history. The experience and opinions of 466 certified prosthetist members of the American Orthotist Prosthetist Association are examined in the second survey, including degree of contact, success, and evaluation of problems in using suction suspension for the B-K amputee. This survey indicated limited contact and familiarity with B-K suction suspension, with only 22% stating they had made this type of prosthesis. Prosthetists cited characteristics of the B-K residual limb as the chief deterrent to a successful fitting.     

Pain in traumatic upper limb amputees in Sierra Leone

Data on 40 upper limb amputees (11 bilateral) with regard to stump pain, phantom sensation and phantom pain is presented. All the patients lost their limbs as a result of violent injuries intended to terrorise the population and were assessed 10-48 months after the injury. All amputees reported stump pain in the month prior to interview and ten of the 11 bilateral amputees had bilateral pain. Phantom sensation was common (92.5%), but phantom pain was only present in 32.5% of amputees. Problems in translation and explanation may have influenced the low incidence of phantom pain and high incidence of stump pain. In the bilateral amputees phantom sensation, phantom pain and telescoping all showed bilateral concordance, whereas stump pain and neuromas did not show concordance. About half the subjects (56%) had lost their limb at the time of injury (primary) while the remainder had an injury, then a subsequent amputation in hospital (secondary). There was no association between the incidence of phantom pain and amputation irrespective of being primary or secondary.