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)
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