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Bilateral Amputation: Prevention, Assessment, Complications & Energy Expenditure

Explore literature review by Craig Evans (June 2006) on bilateral amputation, including causes, prevalence, management, scales for assessment, early rehabilitation, and complications such as DVT, falls, and obesity. Understand energy expenditure differences between walking and wheeling for 2AKAs. Learn about prosthetic solutions, kinematic data, and training methods for better mobility.

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Bilateral Amputation: Prevention, Assessment, Complications & Energy Expenditure

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  1. Bilateral AmputationA Literature review Craig Evans June 2006

  2. The search begins…

  3. 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

  4. 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

  5. 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.”

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

  7. 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)

  8. SCALES From Kulkarni et al (1996) From Devlin et al (2004)

  9. 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

  10. 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 2:2

  11. 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

  12. 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!”

  13. 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

  14. 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

  15. Energy 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???

  16. 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

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

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

  19. 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

  20. 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)

  21. 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

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

  23. 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

  24. Mobility Aides • 4 footed vs 2 wheeled walkers (Tsai et al, 2003, G)

  25. Sitting balance Kirby and Chari, 1990 (G) * = p < 0.05, ^ = p < 0.0001

  26. Outcome 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)

  27. Outcome 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

  28. Outcome 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”

  29. 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

  30. 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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