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Bilateral Amputation A Literature review

Bilateral Amputation A Literature review. Craig Evans June 2006. The search begins…. PREVENTION. Carrington et al, 2001 (G) The efficacy of a focused foot care program for diabetic unilateral amputees in preventing contralateral amputation.

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Bilateral Amputation A Literature review

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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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