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.     

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 pre-operative 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.     

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.     

New developments in recreational prostheses and adaptive devices for the amputee

Regardless of age, conventional prostheses and traditional rehabilitation programs no longer meet the needs and expectations of active amputees. The emphasis on fitness, the availability of stronger and lighter materials, and strong consumer demand have led to plethora of new prosthetic designs by progressive prosthetists and engineers. Prosthetic training techniques now take into account the amputee's recreational and sports needs and desires, using advanced athletic training concepts to achieve superior performance in a wide variety of activities. The surgeon, as a key member of the amputee team, should be aware of these profound changes so that they may contribute his or her skill in surgically crafting an optimally functional residual limb. This will allow the amputee to reach for the maximum in cardiopulmonary fitness while achieving social reintegration after amputation. The combination of skills, concepts, and techniques of the amputation surgeon, prosthetist, and therapist/trainer has led to a unique situation, in which for the first time, amputees are able to successfully compete in sports because of their prostheses, rather than in spite of them.     

Bilateral transtibial amputation with concomitant thoracolumbar vertebral collapse in a Sichuan earthquake survivor

The devastating earthquake in Sichuan, China on 12 May 2008 left thousands of survivors requiring medical care and intensive rehabilitation. In view of this great demand, the Chinese Speaking Orthopaedic Society established the "Stand Tall" project to provide voluntary services to aid amputee victims in achieving total rehabilitation and social integration. This case report highlights the multidisciplinary rehabilitation of a girl who suffered thoracolumbar vertebral collapse and underwent bilateral transtibial amputation. The rehabilitation team was involved in all stages of the care process from the pre-operative phase, through amputation, into prosthetic training, and during her life thereafter. Despite this catastrophic event, early rehabilitation and specially designed bilateral prostheses allowed her a high level of functional ability. The joint efforts of the multidisciplinary team and the advancement of new technology have revolutionized the care process for amputees.     

Comparison of patient-reported outcomes after traumatic upper extremity amputation: Replantation versus prosthetic rehabilitation

BackgroundAfter major upper extremity traumatic amputation, replantation is attempted based upon the assumption that outcomes for a replanted limb exceed those for revision amputation with prosthetic rehabilitation. While some reports have examined functional differences between these patients, it is increasingly apparent that patient perceptions are also critical determinants of success. Currently, little patient-reported outcomes data exists to support surgical decision-making in the setting of major upper extremity traumatic amputation. Therefore, the purpose of this study is to directly compare patient-reported outcomes after replantation versus prosthetic rehabilitation.MethodsAt three tertiary care centers, patients with a history of traumatic unilateral upper extremity amputation at or between the radiocarpal and elbow joints were identified. Patients who underwent either successful replantation or revision amputation with prosthetic rehabilitation were contacted. Patient-reported health status was evaluated with both DASH and MHQ instruments. Intergroup comparisons were performed for aggregate DASH score, aggregate MHQ score on the injured side, and each MHQ domain.ResultsNine patients with successful replantation and 22 amputees who underwent prosthetic rehabilitation were enrolled. Aggregate MHQ score for the affected extremity was significantly higher for the Replantation group compared to the Prosthetic Rehabilitation group (47.2 vs. 35.1, p < 0.05). Among the MHQ domains, significant advantages to replantation were demonstrated with respect to overall function (41.1 vs. 19.7, p = 0.03), ADLs (28.3 vs. 6.0, p = 0.03), and patient satisfaction (46.0 vs. 24.4, p = 0.03). Additionally, Replantation patients had a lower mean DASH score (24.6 vs. 39.8, p = 0.08).ConclusionsPatients in this study who experienced major upper extremity traumatic amputation reported more favorable patient-reported outcomes after successful replantation compared to revision amputation with prosthetic rehabilitation.     

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.     

Combined glenohumeral arthrodesis and above-elbow amputation for the flail limb following a complete posttraumatic brachial plexus injury

The treatment of a severe traction injury resulting in complete, posttraumatic brachial plexus palsy remains a daunting challenge to the upper extremity surgeon. Operative intervention must address painful glenohumeral instability while optimizing functional rehabilitation. Glenohumeral arthrodesis has been shown to reliably alleviate pain from shoulder instability and place the extremity in a functional position for activities of daily living. An above the elbow amputation has also been advocated to remove the flail insensate extremity and create a stable stump for prosthetic training and rehabilitation. We describe the technique of a combined glenohumeral arthrodesis and above elbow amputation to address the flail insensate limb following a severe posttraumatic brachial plexus injury. In our clinical experience, the combination of procedures results in an improved pain level, enhances shoulder stability, encourages functional rehabilitation via prosthetic fitting, and is associated with high patient satisfaction.     

The combined plastic surgery/physical medicine and rehabilitation amputee clinic at the University of Western Ontario

Since the autumn of 2001, a multidisciplinary plastic surgery (PS) and physical medicine and rehabilitation (PMR) outpatient amputee clinic has been in place at St Joseph’s Health Centre/Parkwood Hospital in London, Ontario. To date, more than 140 new patients have been seen in combined consultations. The present paper reviews the demographics, interventions and outcomes of the patients seen between 2001 and 2005. The majority of primary PMR patients had problems that prevented optimal use of their lower extremity prostheses. These problems included nonhealing pressure ulcers, infections, painful neuromas, amputation stump shape abnormalities and fixed joint contractures. Most patients had surgical intervention. In terms of overall clinical success, 53% of the PMR patients and 77% of the PS patients had their problems resolved. The multidisciplinary collaboration in the PS/PMR outpatient amputee clinic provides a unique service that benefits upper and lower extremity amputees.     

Removable rigid dressings: a retrospective case-note audit to determine the validity of post-amputation application

This study investigated the validity of post-amputation application of removable rigid dressings (RRDs) for trans-tibial amputees, regarding preparation for prosthetic management and key rehabilitation timelines. It was hypothesised that the use of RRDs would result in faster preparation of the residual limb for prosthetic management and shorter rehabilitation times, compared with conventional soft dressings. A retrospective case-note audit was conducted, in which consecutive trans-tibial amputees who underwent amputation in the 2 years before RRD implementation (non-RRD group, n = 37) and in the 2 years after RRD implementation (RRD group, n = 28) were eligible for inclusion. There was a significant reduction in the geometric mean time-to-first-prosthetic-casting in the RRD group, compared with the soft-dressing group (36.4 days vs. 27.6 days, respectively, p < 0.05). A significant reduction in acute length of stay (LOS) for the RRD group was also identified (15.9 days vs. 8.7 days, respectively, p < 0.001). There were no significant differences in other rehabilitation timeframes, such as rehabilitation LOS, total LOS, outpatient rehabilitation days, and total rehabilitation days between the two groups. This study shows that the application of RRDs reduces acute LOS and time-to-first-prosthetic-casting, thereby providing substantial benefits in preparing the trans-tibial amputee for early rehabilitation and prosthetic intervention.     

Running patterns of transfemoral amputees: a clinical analysis

The challenge of rehabilitating young, healthy transfemoral amputees may extend beyond the boundaries of teaching them to adapt to functional activities of daily living. The goal for several of these amputees is to participate and sometimes even compete in recreational activities, including running. These amputee runners require prosthetic adaptations as well as a comprehensive individualized training programme to ensure that their running is as safe and energy efficient as possible. To help amputees achieve this, clinicians must understand normal and prosthetic locomotion. This paper compares the biomechanical differences between walking and running in normal locomotion and analyses the running modes used by transfemoral amputees. The modified running mode achieved with the Terry Fox Running Prosthesis subjectively "looks" more energy efficient to the observer and "feels" more energy efficient to the user. These assumptions have yet to be confirmed or refuted by a rigorous scientific research study. An outline of the proposed physiotherapy protocol includes the familiarization, treatment, and training phases. Physiotherapists involved in amputation rehabilitation may not be commonly confronted with this level of patient expectation. It is their responsibility to give realistic guidance to these amputees so that they can safely and independently pursue their recreational running activities. This need can best be fulfilled by providing sound clinical advice which has been validated by research findings.     

Daily functioning of patients with an amputated lower extremity

The National Center for Health statistics estimates more than 300,000 individuals with major lower extremity amputation currently are living in the United States. Current healthcare climate mandates effective rehabilitation be provided in the most effective manner. An interdisciplinary amputee team approach to rehabilitation with active participation of the patient should be implemented early in the preamputation period to facilitate short hospital stays and earlier return to productivity with associated cost savings. This paper discusses preoperative assessment and education, postoperative intervention, and indications for inpatient rehabilitation. Gait training with prosthesis in simple and complex environments, assistive devices needed for effective functioning at home, and prosthetic modification for participation in recreational activities are reviewed along with issues related to vocational rehabilitation.     

Results of rehabilitation after double-sided prosthetic provision of lower limbs]

FORMULATION OF THE QUESTION: As a problem stood the question what effect the progress in orthopedic technology during the last years had on the rehabilitation results of the persons affected and how etiology and distribution of age and sex have changed. METHOD: We post-examined 50 patients during home visits who had had double-sided amputations of lower limbs and were provided from 1985 to 1993 were examined at home. RESULTS: Etiologically it concerns 25 patients with chronic arterial circulatory disturbances, 10 with trauma, 7 with congenital damages and 8 with consequences of other amputation causes. The rehabilitation results are to be evaluated with good. It could be proved that also elder double-sided amputees can be prosthetically rehabilitated if at least one knee joint could be maintained. The physiotherapeutic post-care was recognized as the weak point of rehabilitation, it has to be improved especially for the elder persons affected. CONCLUSION: The elder double-sided amputee can be enabled to a safe walk on prostheses only by optimum rehabilitation management with quick prosthetic provision and early starting intensive physiotherapeutic post-care which should go on for a much longer time than the stay in hospital.     

Factors related to successful upper extremity prosthetic use

Surveys from 40 upper extremity amputees were analyzed to examine factors related to successful use of an upper extremity prosthesis. Factors which were associated with successful rehabilitation were fewer than two complicating factors, completion of high school education, employment at both the time of amputation and review, rapid return to work, acceptance of the amputation by the time of this review, and perception that the prosthesis was expensive. Factors which appeared unrelated to prosthetic success were age, loss of dominant hand, loss of elbow, marital status, use of rehabilitation services, use of a temporary prosthesis, and whether training in prosthetic use was provided. Many of these factors concurred with earlier studies. Previously unreported factors that may be of importance to the long-term success of upper limb amputees are the number of complicating factors and perceptions about the monetary value of the prosthesis.     

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.     

Characterisation and outcomes of upper extremity amputations

Background

The purpose of this study is to characterise the injuries, outcomes, and disabling conditions of the isolated, combat-related upper extremity amputees in comparison to the isolated lower extremity amputees and the general amputee population.

Methods

A retrospective study of all major extremity amputations sustained by the US military service members from 1 October 2001 to 30 July 2011 was conducted. Data from the Department of Defense Trauma Registry, the Armed Forces Health Longitudinal Technology Application, and the Physical Evaluation Board Liaison Offices were queried in order to obtain injury characteristics, demographic information, treatment characteristics, and disability outcome data.

Results

A total of 1315 service members who sustained 1631 amputations were identified; of these, 173 service members were identified as sustaining an isolated upper extremity amputation. Isolated upper extremity and isolated lower extremity amputees had similar Injury Severity Scores (21 vs. 20). There were significantly more non-battle-related upper extremity amputees than the analysed general amputation population (39% vs. 14%). Isolated upper extremity amputees had significantly greater combined disability rating (82.9% vs. 62.3%) and were more likely to receive a disability rating >80% (69% vs. 53%). No upper extremity amputees were found fit for duty; only 12 (8.3%) were allowed continuation on active duty; and significantly more upper extremity amputees were permanently retired than lower extremity amputees (82% vs. 74%). The most common non-upper extremity amputation-related disabling condition was post-traumatic stress disorder (PTSD) (17%). Upper extremity amputees were significantly more likely to have disability from PTSD, 13% vs. 8%, and loss of nerve function, 11% vs. 6%, than the general amputee population.

Discussion/conclusion

Upper extremity amputees account for 14% of all amputees during the Operation Enduring Freedom and Operation Iraqi Freedom conflicts. These amputees have significant disability and are unable to return to duty. Much of this disability is from their amputation; however, other conditions greatly contribute to their morbidity.     

Mobility outcome following unilateral lower limb amputation

This study investigated mobility outcome following unilateral trans-tibial or trans-femoral amputation. It was an observational study at the sub-regional amputee rehabilitation centre in Sheffield, UK. All unilateral trans-tibial or transfemoral amputees referred during the study period were included. The Harold Wood Stanmore mobility grade was recorded approximately one year following initial assessment at the centre. Of the 357 amputees referred, complete outcome data was available for 281 (78.7%). The mean age was 68 years (range 16-95), 70.1% were male, and the aetiology of the amputation was vascular or diabetic in 87.5% of cases. Trans-tibial amputations accounted for 50.5% and trans-femoral 49.5%. Almost all trans-tibial and trans-femoral amputees aged 50 and under achieved functional household and community mobility. Approximately 50% of the trans-tibial amputees aged over 50 years gained independent community mobility and around 60% household mobility. There was a significant worsening of community mobility rates with increasing age but for household mobility the differences did not reach statistical significance. Fewer than 25% of trans-femoral amputees aged over 50 achieved community mobility and around 50% achieved household mobility. There was a statistically significant deterioration in both community and household mobility levels with increasing age. This study concludes that mobility rates one year after prosthetic provision for unilateral trans-tibial and trans-femoral amputees worsen with increasing age at amputation and a higher level of amputation.     

A functional evaluation of prosthetic foot kinematics during lower-limb amputee gait

This paper reports on a functional evaluation of prosthetic feet based on gait analysis. The aim is to analyse prosthetic feet behaviour under loads applied during gait in order to quantify user benefits for each foot. Ten traumatic amputees (six trans-tibial and four trans-femoral) were tested using their own prosthetic foot. An original protocol is presented to calculate the forefoot kinematics together with the overall body kinematics and ground reaction forces during gait. In this work, sagittal motion of the prosthetic ankle and the forefoot, time-distance parameters and ground reaction forces were examined. It is shown that an analysis of not only trans-tibial but also trans-femoral amputees provides an insight in the performance of prosthetic feet. Symmetry and prosthetic propulsive force were proved to be mainly dependant on amputation level. In contrast, the flexion of the prosthetic forefoot and several time-distance parameters are highly influenced by foot design. Correlations show influential of foot and ankle kinematics on other parameters. These results suggest that prosthetic foot efficiency depends simultaneously on foot design and gait style. The evaluation, proposed in this article, associated to clinical examination should help to achieve the best prosthetic foot match to a patient.