Bilateral Amputation A Literature review

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Bilateral AmputationA Literature review

• Craig Evans
• June 2006

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The search begins
CATEGORY ARTICLES
Case studies (C) 2TT TT/TF 2TF 2UL Other 30 12 3 0 9 6
General inc. 2AMPs (G) 24
2AMP focus (F) 8
2AMP UL 13
Prosthetics 16
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PREVENTION

• 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

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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

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Aetiology

• 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.

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PREVALENCE

• In patients on haemodialysis (n 232)
• 13.4 had amputations ranging from single toes to
  2TF amputations
• Locking-Cusolito et al, 2005 (G)

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ASSESSMENT

• 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)

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

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COMPLICATIONS

• 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 22

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COMPLICATIONS

• 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

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COMPLICATIONS

• 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!

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Energy 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

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Energy 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

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Energy Expenditure

• Able bodied vs 2AKAs with SL and LL prostheses
  (Crouse et al, 1990, C)
• HR and Oxygen Uptake
• LL gt SL gt Controls
• VO2 max 56 lt age predicted values
• Reduced amount of mm tissue active during
  walking???

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Energy 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

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Bilateral Hip Disarticulation

• Severe complications of SCI
• Accident trauma
• Congenital anomalies
• Malignancy
• Large benign tumours
• Osteomyelitis of pelvis
• Mainly Case studies, case series data

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Bilateral Hip Disarticulation

• Carlson and Wood, 1998 (C)
• Marked volume fluctuation
• Shear trauma
• Heat dissipation
• Versatile and functional
• Reduced sensation in SCI

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Bilateral Hip Disarticulation

• Rogers et al, 1993 (C)
• Mx of 49 y.o. with SCI and BHD
• Prosthesis for
• Sitting support
• Cosmesis
• Ambulation opportunities
• PAC

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Bilateral Hip Disarticulation

• 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)

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Kinematic 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

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Prosthetic solutions

• St-Jean and Goyette, 1996 (C)
• 2BKAs fitted with 2 types of skating prostheses

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Training

• 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

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Mobility Aides

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

Walker Speed (m/sec)
FFW 0.27
TWW 0.5
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Sitting balance Kirby and Chari, 1990 (G)
Bilateral amputees Prostheses on Prostheses off Mean difference
Straight forward Thigh support Ischial support 94.3 58.5 104.4 99.7 10.1 41.2
Anterolateral (45 degrees) Thigh support Ischial support 102.3 74.7 110.9 106.2 8.6 31.5
p lt 0.05, p lt 0.0001
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Outcome Studies

• 2AKAs from Vietnam War (Dougherty, 1999, F)
• 6 2AKAs
• 57 fitted with prostheses at 6.4 months
• 22 still wore them (avg. gt7 hours / day)
• SF-36 were normal
• More positive outcomes officers
• Not condemned to severe physical and emotional
  problems. (e.g. Forest Gump Sergeant)

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Outcome Studies

• Factors influencing reintegration to normal
  living (Nissen and Newman, 1992, G)
• 26 bilateral amputees
• Bilateral amputation didnt alter RNL scores,
  Amputation illness did
• Pre amp function severely limited

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Outcome Studies

• Experience with 80 2BKAs (Thornhill et al, 1986,
  F)
• Inner city African Americans
• 86 arterial disease
• lt 6 year contralateral limb survival
• 71 prosthetic usage
• Non-use mental impairment

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Outcome 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

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SUMMARY

• Bilateral amputees provide a unique opportunity
  for
• Research
• Innovation
• Mobility is the key to functional (?successful)
  outcome.
• Complications of decreased mobility

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