Bilateral AmputationBilateral AmputationA Literature reviewA Literature review

Craig Evans

June 2006

The search begins…CATEGORY ARTICLES

Case studies (C)2TT

TT/TF

2TF

2UL

Other

3012

3

0

9

6

General inc. 2AMPs (G) 24

2AMP focus (F) 8

2AMP – UL 13

Prosthetics 16

PREVENTIONPREVENTION

Carrington et al, 2001 (G)– The efficacy of a focused

foot care program for diabetic unilateral amputees in preventing contralateral amputation.

– No significant reduction in bilateral amputation rate

– There was limited, inconsistent follow up

– Aggressive wound care and revascularization

Prevention (?)Prevention (?)

• TMT Amputation breakdown (Mueller et al, 1995, G)

– 12% 2TMT – no specific conclusions– 27% breakdown rate– 28% revision rate– Acute Mx – Protection!– Rehab – Protect with appropriate footwear

and prosthesis

AetiologyAetiology

• Bilateral TKR infection (Wolff et al, 2003, G)

– 1/21 over 23 years with simultaneous TKR infection required bilateral AKA

• Burns (Acikel et al, 2001, C Abs)

– “The post operative period was uneventful.”

PREVALENCEPREVALENCE

In patients on haemodialysis (n = 232)

• 13.4% had amputations ranging from single toes to 2TF amputations

Locking-Cusolito et al, 2005 (G)

ASSESSMENTASSESSMENT

• Harold Wood (Kulkarni et al, 1996, G)

• Houghton scale (Devlin et al, 2004, G)

• 2 minute walk test (Brooks et al, 2001, G)

• Custom socket and refurbished 2nd hand modular components (Marzoug et al, 2003, G Abs).

• Ergometry (Vestering et al, 2005, G)

SCALESSCALES

From Devlin et al (2004)From Kulkarni et al (1996)

EARLY MANAGEMENTEARLY MANAGEMENT

Faucher and Schurr, 2005 (C)

• Accelerated rehabilitation using early mobilization (Day 1 post-op!) on thigh high rigid casts with feet and pylons.– Appropriate patient selection – no problems

that may complicate wound healing

COMPLICATIONSCOMPLICATIONS

• DVT/PE (Zickler et al, 1999, F)• 26% of 2AMPs• Immobile after 2nd amputation• Males

• Falls (Kulcarni et al, 1996, G)• 27% (4) had falls• Prostheses worn 2:2

COMPLICATIONSCOMPLICATIONS

• Obesity (Kurdibaylo, 1996, G, Abs)• 2TF & TT/TF had:

– highest fat in body mass (25.9%)– 64.2% frequency of obesity progression

• Pain– RSD/CRPS

• Viejo and Viladomat, 1996 (G, Abs)

– Phantom pain• Dijkstra et al, 2002 (G, Abs)• Zuckweiler, 2005 (C) - Mental imagery

COMPLICATIONSCOMPLICATIONS

• Heterotopic Ossification (Warmoth et al 1997, C)

• Mature trabecular bone (bony spur)• Prosthetic limbs worn without

consequence

• Litigation! (Tammelleo, 1999)• “Pt sues for bilateral leg

amputations: physicians are not “guarantors” of results!”

Energy ExpenditureEnergy Expenditure

2AKA Walking vs. Wheeling (Wu et al, 2001, C)

• Variety of prosthetic variation used (Stubbies to LL and crutches)

• Walking compared to wheeling:• O2 cost 466-707% • HR 106-116% • Distance 23-33%

• Wheelchair propulsion - more energy efficient for 2AKAs

Energy ExpenditureEnergy Expenditure

• Able Bodied vs. 2AKAs (Hoffman et al 1997, F)

– Variable prosthetic componentry– Matched subjects (1 twin)– 2AKAs had higher Ve, Vo2, HR

& perceived exertion– Slower chosen walking speed – Model for metabolic cost

• Increased due to: – Posture and balance

– Energy absorption

Energy ExpenditureEnergy Expenditure

• Able bodied vs 2AKAs with SL and LL prostheses (Crouse et al, 1990, C)

– HR and Oxygen Uptake• LL > SL > Controls

– VO2 max 56% < age predicted values• Reduced amount of mm tissue active during

walking???

Energy ExpenditureEnergy Expenditure

• Stubbies vs. “Conventional legs” vs C-legs (Perry et al, 2004, C)

• C-leg – walked “farther and faster”– Longer stride length– Lower O2 Uptake

• “reduction in muscular effort”

– Higher resting heart rate

Bilateral Hip Bilateral Hip DisarticulationDisarticulation

• Severe complications of SCI

• Accident trauma• Congenital anomalies• Malignancy• Large benign tumours• Osteomyelitis of pelvis

• Mainly Case studies, case series data

Bilateral Hip Bilateral Hip DisarticulationDisarticulation

• Carlson and Wood, 1998 (C)– Marked volume

fluctuation– Shear trauma – Heat dissipation– Versatile and

functional– Reduced sensation in

SCI

Bilateral Hip Bilateral Hip DisarticulationDisarticulation

• Rogers et al, 1993 (C)• Mx of 49 y.o. with SCI

and BHD• Prosthesis for :

– Sitting support– Cosmesis– Ambulation

opportunities– PAC

Bilateral Hip Bilateral Hip DisarticulationDisarticulation

• Sitting Orthosis/Prosthesis enabling wheelchair mobility in a patient with BHD and (L) CVA (Oryshkevich et al, 1984, C)

• Thoracic Suspension Orthosis / Prosthesis to aid pressure area care (Rindflesch and Miller 2002, Abs)

Kinematic and Kinetic DataKinematic and Kinetic Data

White et al, 2000 (C)• PTB + SACH vs 3-S + Flex foot• Sagittal kinematic data – increased ankle

motion• Trend toward increased:

• Velocity• Cadence• Stride Length• (R) Step length (?)• Energy return

Prosthetic solutionsProsthetic solutions

St-Jean and Goyette, 1996 (C)

• 2BKAs fitted with 2 types of skating prostheses

TrainingTraining

• Treadmill training for a 2BKA with COPD (Adler et al, 1987, C)

– Initial Walking with pylons 12-24m– Progressive exercise regime– Managed 1.2mph / 2% grade for 30 mins

• Improved cardiac condition & endurance

• Managed stairs, gardening, household chores

Mobility AidesMobility Aides

• 4 footed vs 2 wheeled walkers (Tsai et al, 2003, G)

Walker Speed

(m/sec)

FFW 0.27

TWW 0.5

Sitting balance Sitting balance Kirby and Chari, 1990 (G)

Bilateral amputees

Prostheses on Prostheses off Mean difference

Straight forward

Thigh support

Ischial support94.3

58.5

104.4

99.7

10.1*

41.2^

Anterolateral (45 degrees)

Thigh support

Ischial support102.3

74.7

110.9

106.2

8.6

31.5^

* = p < 0.05, ^ = p < 0.0001

Outcome StudiesOutcome Studies

• 2AKAs from Vietnam War (Dougherty, 1999, F)

• 6% 2AKAs• 57% fitted with prostheses at 6.4 months• 22% still wore them (avg. >7 hours / day)• SF-36 were “normal”• More positive outcomes – officers• Not condemned to severe physical and emotional

problems. (e.g. Forest Gump Sergeant)

Outcome StudiesOutcome Studies

• Factors influencing reintegration to normal living (Nissen and Newman, 1992, G)

• 26% bilateral amputees

• “Bilateral amputation” didn’t alter RNL scores, Amputation + illness did

• Pre amp function – severely limited

Outcome StudiesOutcome Studies

• Experience with 80 2BKAs (Thornhill et al, 1986, F)

– Inner city African Americans– 86% arterial disease– < 6 year contralateral limb survival– 71% prosthetic usage– Non-use – “mental impairment”

Outcome StudiesOutcome Studies

• Inner city dwelling, atherosclerotic 2BKAs (Brodzka et al, 1990)

– 45.8% wheelchair inaccessible buildings– 20/24 prosthetic issue– 12/20 still wore them, 50% could ambulate– 17/20 walked signiciantly post 2BKAs– Lost ambulatory skills – older, shorter amp to

amp interval– Only 1 fully dependant – Mobility = key to functional outcome

SUMMARYSUMMARY

• Bilateral amputees provide a unique opportunity for:

• Research• Innovation

• Mobility is the key to functional (?successful) outcome.

• Complications of decreased mobility