[Lower limb amputations and rehabilitation]. / Benamputasjon og rehabilitering.

BACKGROUND We wished to study the therapy for lower limb amputees at Sørlandet Hospital Kristiansand after restructuring of activities in 2004.MATERIAL AND METHOD All lower limb amputees hospitalised in the Department of Physical Medicine and Rehabilitation between March 2012 and July 2015 were followed up prospectively.RESULTS A total of 50 patients with 54 amputations were followed up for at least three months. Altogether 31 transtibial amputations, 22 transfemoral amputations and one knee disarticulation were performed. The median age of the patients was 66 years, 36 of whom were men, median Charlson comorbidity index was 1.5, 14 smoked, 8 were substance abusers, 9 were able to walk at least 2 km preoperatively, 44 of the amputations were performed with myodesis, and 41 patients were transferred directly to the Department of Physical Medicine and Rehabilitation. At the three-month check-up, 48 patients used their custom-made prostheses, average walk-test time was 21 seconds, and 45 lived in their own home. At the one-year check-up, 32 of 35 patients who attended used prostheses, and average walk-test time was 18 seconds. Use of painkillers declined during the period. Advanced age, transfemoral amputation and substance abuse were associated with longer walk-test time at the three-month check-up.INTERPRETATION Most patients achieved a good level of function, and the therapy appears to be functioning satisfactorily.

Factors affecting successful prosthetic use after hemipelvectomy and hip disarticulation amputations: Five-year experience from a tertiary prosthetic rehabilitation center.

BACKGROUND: Rehabilitation after hip disarticulation and hemipelvectomy amputations can be challenging, and many opt to forego prosthetic limb use. There is limited evidence on characteristics that result in successful prosthetic use; therefore, our study aimed to identify these to help guide patient expectations. METHODS: A retrospective review was performed on patients seen at a UK tertiary prosthetic center in the past 5 years with hip disarticulation or hemipelvectomy amputations. Details and etiology of amputation, length between assessment and delivery of prosthesis, goals, reasons for abandonment, and outcomes were recorded. Successful prosthetic use was defined as the use of a prosthesis at least 3 times a week. Characteristics were compared using odds ratios and Fisher exact test. RESULTS: Twenty-seven patient notes were analyzed: 42% female, 58% male, and age range 14-90. Thirty percent had a hemipelvectomy, and 70% had a hip disarticulation. Neoplasia accounted for 78% of etiologies followed by trauma 15% and infected endoprosthesis 7%. Sixty-seven percent trialed a walking prosthesis; 33% of these stopped eventually. There were no statistically significant findings of factors increasing odds of successful prosthetic use. However, age significantly increased the odds of being given a trial of a prosthesis. CONCLUSION: Although younger patients are more likely to be given the opportunity to trial a walking prosthesis, age does not seem to affect the overall outcome alone. In cases of neoplasia, there is often a delayed start to rehabilitation and prosthetic use, which may affect eventual success. Further studies are required to define the optimum characteristics for successful prosthetic use at higher amputation levels.

Syme Amputation: A Systematic Review.

BACKGROUND: In the decision-making process toward an amputation of the lower extremity, knowledge about patient-related outcomes after amputation and rehabilitation is important. We have not found a systematic review that provides this knowledge for Syme amputation. The aim of this study was to present an overview of outcomes after a Syme amputation grouped according to the International Classification of Functioning, Disability and Health (ICF) model, focusing on body structures and functions, activities, and participation. METHODS: A systematic literature search was performed. Included studies went through 2 selection procedures by 2 independent assessors. Included were all studies concerning Syme amputation with patient-related outcomes. RESULTS: Thirty-six studies were included for data extraction, concerning 1056 patients (238 children and 818 adults). Heel pad migration was reported in 49 of 176 (28%), skin problems in 23 of 128 (18%), and bone problems in 42 of 145 (29%) children. No reamputations were reported. All children were fitted with a prosthesis, and 62 of 90 (69%) children participated in sports. Skin problems were reported in 35 of 195 (18%), ulceration or infection in 120 of 512 (23%), residual limb pain in 46 of 181 (25%), and reamputations in 180 of 919 (20%) adults. In total, 247 of 363 (68%) adults were fitted with a prosthesis. Walking aids were used by 45 of 135 (33%) adults. Employment status was unchanged in 147 of 209 (72%) adults. CONCLUSION: In children, no reamputations were necessary and few complications were reported, with good participation in daily life in the majority of children. In adults, more complications and reamputations were reported; nevertheless, most adult amputees became successful prosthesis users. LEVEL OF EVIDENCE: Therapeutic Level III, systematic review containing retrospective cohort studies.

Successful First Gait of a Child With Hip-Disarticulation Prosthesis.

An infant boy underwent hip disarticulation for infantile fibrosarcoma immediately after birth. His rehabilitation began when he was 4 mos old and involved training with his left (residual) leg. He could stand with support at 12 mos. His initial prosthesis fitting was performed at the age of 13 mos. He could stand and walk with support at 15 mos of age and could walk with no additional support and go up and down stairs at 2 yrs. A single-axis prosthetic knee joint was introduced at the age of 2 yrs 3 mos. His first gait using a hip prosthesis was successful, and his prosthesis was replaced at appropriate intervals with no major problems. The authors believe that the key to achieving a successful prosthetic gait in children is good communication among the medical team, which should comprise an orthopedic doctor, rehabilitation doctor, nurse, physical therapist, prosthetist/orthotist, and the patient's parents.

Functional Outcomes of Service Members With Bilateral Transfemoral and Knee Disarticulation Amputations Resulting From Trauma.

As longitudinal studies for those with bilateral transfemoral amputation (BTFA) or knee disarticulation (KD) are lacking, it is important to quantify performance measures during rehabilitation in an effort to determine reasonable expectations and trends that may influence the rehabilitation process. At initial evaluation (date of first independent ambulation) and follow up (median 135 [range = 47-300] days later), 10 participants with BTFA/KD completed 6 minute walk testing and Activity Specific Balance Confidence and Lower Extremity Functional Scale questionnaires. Of these, six participants also completed stair ambulation; ascent time and stair assessment index (SAI) scores were calculated. Patients utilized their prescribed prostheses at each visit. Participants were able to cover a significantly greater distance (135.3 [70.1] m) in 6 minutes at the follow-up visit (*p = 0.005). The change in SAI scores for stair ascent and descent was not statistically significant (p = 0.247). Stair ambulation confidence scores were significantly greater at the final visit (*p = 0.034). Stair negotiation appears to plateau early; however, confidence builds despite absence of functional gains over time. Service members with BTFAs/KDs are able to achieve functional community ambulation skills. Thus, this investigation suggests that clinicians can realign rehabilitation paradigms to shift focus towards community distance ambulation once safe stair ascent and descent is achieved.

Prosthetic Rehabilitation After Hip Disarticulation or Hemipelvectomy.

OBJECTIVE: Prosthetic rehabilitation after pelvic-level amputation (hemipelvectomy/hip disarticulation) is difficult, and because of this, many patients are never fit with a prosthetic limb. The objectives of the study were to evaluate the characteristics of successful prosthetic users and to determine what factors are associated with successful prosthetic fitting and use. DESIGN: The authors identified 43 patients who underwent hip disarticulation/hemipelvectomy between 2000 and 2010 and were candidates for prosthetic fitting at the authors' institution. The medical records of these patients were then reviewed for pertinent demographic and medical characteristics to identify the profile of successful prosthetic users. RESULTS: Of 43 patients, 18 (43%) successfully used a prosthetic limb. The only preoperative factor associated with unsuccessful prosthetic fitting was coronary artery disease. Specifically, age, body mass index, other medical comorbidities, and demographic characteristics were not associated with successful or unsuccessful prosthetic fitting. Successful users wore their prosthesis an average of 5.8 hrs/day, and most ambulated with one or both hands free. CONCLUSIONS: Successful prosthetic rehabilitation after hemipelvectomy and hip disarticulation is possible. Increased body mass index, advanced age, depression, and other comorbidities should not discourage prosthetic rehabilitation. Most patients that undergo prosthetic rehabilitation enjoy long periods of survival and wear their prosthesis for most of the day.

Development of a cosmetic knee disarticulation prosthesis: A single-patient case study.

BACKGROUND AND AIM: If a person does not become ambulant after an amputation, a knee disarticulation (KD) shouldbe considered and the person may then benefit from a cosmetic KD prosthesis. The features of a cosmetic KD prosthesis are, however, seldom described. The aim of this clinical note is to describe the development of a cosmeticKD prosthesis. TECHNIQUE: A non-ambulant person with bilateral KD formulated, together with her physiatrist, the criteria for a cosmetic KD prosthesis. On the basis of these, a lightweight, natural-looking, well-fitting, easy-to-put-on and take-off KD prosthesis, with no thigh lengthening during sitting, was made. This prosthesis was fixed on a wheelchair and does not impede transfer. DISCUSSION: A newly constructed cosmetic prosthesis for non-ambulant persons with a KD is described in detail. We hope that this will encourage physiatrists and prosthetists to offer non-ambulant persons with a KD a cosmetic prosthesis. CLINICAL RELEVANCE: A cosmetic leg prosthesis with good cosmetic properties, good sitting comfort, and no restrictions in making transfers is described in detail for non-ambulant persons with a knee disarticulation.

Selection of patients for through-the-knee amputation.

Forty-six adult patients had a through-the-knee amputation (disarticulation of the knee) in a four-year period. Thirty-four of the patients had peripheral vascular insufficiency and were judged to lack the potential for using a prosthesis functionally, although the evaluation indicated that they had the potential for healing of the wound at the below-the-knee level of amputation. At a minimum follow-up of one year, the amputation wound had healed in thirty of these patients, and no joint contracture had developed. Two patients died in the first postoperative month, and two had failure to heal and needed revision to an above-the-knee amputation. The remaining twelve patients who had a through-the-knee amputation were judged to be potentially able to use a prosthesis functionally, but they did not have the capacity for wound-healing at the below-the-knee level. Therefore, in these patients, a through-the-knee amputation was performed as an alternative to an above-the-knee amputation. The amputation wound healed in eight of these patients, but four (33 per cent) had failure to heal and needed subsequent revision to an above-the-knee amputation. All twelve patients were able to use a prosthesis. The through-the-knee amputation provides good muscular balance and has a low risk for the late development of joint contracture. The residual limb (stump) provides an excellent surface area for sitting balance and a lever-arm for transfer. In a patient who has the potential to use a prosthesis functionally, the residual limb allows direct load-transfer (end weight-bearing).(ABSTRACT TRUNCATED AT 250 WORDS)

A feasibility trial of a prefabricated immediate postoperative prosthetic limb system.

In this feasibility trial, 32 consecutive patients undergoing transtibial or knee disarticulation amputation had application of a prefabricated immediate postoperative prosthesis in the operating room following lower extremity amputation. Partial weightbearing was initiated on the first postoperative day. Twenty-nine underwent primary amputation as a consequence of nonsalvageable gangrene or diabetic foot infection. Others were performed at the time of wound closure following traumatic amputation for a crushed extremity and one was performed for an infected nonunion of the tibia and fibula. Seventeen of the 29 patients with diabetes were insulin dependent. Nine patients required renal dialysis and were diagnosed with concurrent malnutrition. Twenty were male and 12 were female, with an average age of 61.6 (range, 42-90) years. The average time to custom prosthetic limb fitting was 8.1 (range, 4-16) weeks. This preliminary experience with a commercially available pneumatic immediate postoperative prosthetic limb system supports its role in the early rehabilitation of lower extremity amputees.

Knee-disarticulation.

The disarticulation of the knee joint is--in contrary to the above-knee level--a fast and tender method for amputation, resulting in a vigorous, complete weightbearing stump. Without problems the bulky stump is fitted in an exactly moulded plastic or resin socket--eventually combined with a soft socket--, which can be easily put on and off also by older patients suffering from general dysvascular disorders. Nowadays special joints are used for functionally as well as cosmetically satisfying knee-disarticulation-prostheses. The surgical technique with alternative incisions, the peculiarities in dysvascular patients, the postoperative care including immediate or early fitting, the management after wound-healing with a temporary exercise-prosthesis and finally the various possibilities of the definitive prosthetic fitting are stressed in detail.

Case report: occupational therapy with a traumatic bilateral shoulder disarticulation amputee.

This report describes the application of occupational therapy to a patient with traumatic bilateral shoulder disarticulation. Treatment goals and methods for acute care, preprosthetic training, and prosthetic training are described and illustrated.

The use of snowboard boot bindings in a hip disarticulation prosthesis.

This report describes a new technique for fastening a hip disarticulation socket. It was developed at the request of the patient who needed to fasten his prosthesis using only one hand, because of a left upper limb disability. Snowboard boot bindings were secured to the socket of the prosthesis and allowed it to be securely fastened and released using his dominant hand only. The design of the bindings permitted a high closing force with minimum one-handed effort by the user.

A newly developed socket design for a knee disarticulation amputee who is an active athlete.

This case report describes a newly developed socket design for a world class knee disarticulation athlete. To meet the demands concerning especially the suspension of the prosthesis a new type of socket was developed. The socket is made from carbon fibres and polyaramid fibres and is designed with a slit in the socket creating a flexible flap. This allows the amputee to both increase and decrease the inner circumference of the socket, thereby allowing the amputee to adjust the socket to stump variations. According to the amputee the new design offers an excellent fit and enables him to concentrate fully on the technical aspects of the different disciplines.

Does the new Helix 3D hip joint improve walking of hip disarticulated amputees?

PURPOSE: Testing the new hip joint Helix3D efficiency through clinical data and walking parameters. METHOD: Three young hip-disarticulated patients (P1, P2 and P3) were assessed both with their previous prosthesis at first day, then four days and six months after being trained with a new prosthesis equipped with the Helix3D hip joint. Assessments comprised a satisfaction questionnaire, a two-minute walk test and a recording of main spatiotemporal gait parameters RESULTS: After four days with the Helix3D, the satisfaction for the prosthesis was improved for P1, unchanged for P2 and reduced for P3. Distance walked during two minutes increased for P1, unchanged for P2 and slightly improved for P3. Gait pattern was improved in P1, only. P1 abandoned the Helix3D at six months due to an ischiatic wound. P2 and P3 chose not to use the Helix at the end of the four days training period because they could not adapt to the Helix3D characteristics (hydraulic control of hip extension and assistance to hip flexion) and because they did not gain enough benefits. Despite much effort to adjust the prosthesis, the three patients definitively abandoned the Helix3D because of comfort problems, and decided to walk with their previous prosthesis equipped with a monocentric hip joint or even with crutches only. CONCLUSION: The Helix3D hip joint may need further developments to get clinically relevant for hip-disarticulated amputees who may also need a long training period to adapt to its technical characteristics.

Compensatory-step training of healthy, mobile people with unilateral, transfemoral or knee disarticulation amputations: A potential intervention for trip-related falls.

The purpose of this study was to evaluate the effects of compensatory-step training of healthy, mobile, young-to-middle aged people with unilateral, transfemoral or knee disarticulation amputations. Outcomes of interest included recovery success, reliance on the prosthesis, and the kinematic variables relevant to trip recovery. Over the course of six training sessions, five subjects responded to postural disturbances that necessitated forward compensatory steps to avoid falling. Subjects improved their ability to recover from these postural disturbances without falling or hopping on the non-prosthetic limb. Subjects improved their compensatory stepping response by decreasing trunk flexion and increasing the sagittal plane distance between the body center of mass and the stepping foot. In response to more challenging disturbances, these training-related improvements were not observed for the initial step with the non-prosthetic limb. Regardless of the stepping limb, step length and the change in pelvic height were not responsive to training. This study exhibits the potential benefits of a compensatory-step training program for amputees and informs future improvements to the protocol.

Influence of advanced prosthetic knee joints on perceived performance and everyday life activity level of low-functional persons with a transfemoral amputation or knee disarticulation.

OBJECTIVE: To assess the effects of two types of microprocessor-controlled prosthetic knee joints (MPKs) on perceived performance and everyday life activity level. DESIGN: Randomized cross-over trial. SUBJECTS: Thirty persons with a unilateral above-knee amputation or knee disarticulation classified as Medicare Functional Classification Level-2. METHODS: Participants were measured in 3 conditions, i.e. using a mechanically controlled prosthesis, an MPK featuring a microprocessor-controlled stance and swing phase (MPKA), and an MPK featuring a microprocessor-controlled stance phase (MPKB). Subjects' perceived performance regarding prosthesis use was measured with the Prosthesis Evaluation Questionnaire. Subjects' activity level was quantified using accelerometry. As high within-group variability regarding subjects' functional performance was expected to impede detection of possible effects of an MPK, data were analysed for the total group and for 3 subgroups of participants. RESULTS: Participants' perception regarding ambulation, residual limb health, utility, and satisfaction with walking were significantly higher in the MPKA condition compared with the mechanical knee joint condition. Participants' activity level was similar in all knee joint conditions. CONCLUSION: Although Medicare Functional Classification Level-2 amputees report benefitting in terms of their performance from using an MPK, this is not reflected in their actual daily activity level after one week of using an MPK.

Use of two-axis joystick for control of externally powered shoulder disarticulation prostheses.

We explored a new method for simple and accurate control of shoulder movement for externally powered shoulder disarticulation prostheses with a two-axis joystick. We tested 10 subjects with intact shoulders and arms to determine the average amount of shoulder motion and force available to control an electronic input device. We then applied this information to two different input strategies to examine their effectiveness: (1) a traditional rocker potentiometer and a pair of force-sensing resistors and (2) a two-axis joystick. Three nondisabled subjects and two subjects with shoulder disarticulation amputations attempted to control an experimental externally powered shoulder using both control strategies. Two powered arms were tested, one with powered flexion/extension and humeral rotation and one with powered flexion/extension and adduction/abduction. Overwhelmingly, the subjects preferred the joystick control, because it was more intuitively linked with their shoulder movement. Additionally, two motions (one in each axis) could be controlled simultaneously. This pilot study provides valuable insight into an effective means of controlling high-level, externally powered prostheses with a two-axis joystick.

Energy consumption during prosthetic walking and wheelchair locomotion by elderly hip disarticulation amputees.

OBJECTIVE: To investigate the differences in energy consumption by patients with hip disarticulation between prosthetic walking and wheelchair locomotion. DESIGN: : The subjects consisted of seven amputees, all older than 60, with unilateral hip disarticulation. Energy consumption when walking with prosthesis and when propelling a wheelchair, each at the respective comfortable movement speed, was measured by means of a portable telemetric system. RESULTS: The average comfortable movement speed for prosthetic walking was 30.5 m/min, which was much slower than the 63.1 m/min average for wheelchair locomotion (P < 0.01). The average oxygen cost value for prosthetic walking was 0.639 ml/kg/m, and the average for wheelchair locomotion was 0.175 ml/kg/m, indicating that oxygen cost was significantly higher for prosthetic walking than for wheelchair locomotion (P < 0.01). CONCLUSIONS: The results of this research clearly showed that the efficiency of prosthetic walking for elderly hip disarticulation amputees was very low. When the subject is judged not to be a candidate for practical prosthetic walking after a careful multidisciplinary evaluation, wheelchair locomotion may be an alternative to prosthetic walking as a realistic goal.

Spatial filtering improves EMG classification accuracy following targeted muscle reinnervation.

The combination of targeted muscle reinnervation (TMR) and pattern classification of electromyography (EMG) has shown great promise for multifunctional myoelectric prosthesis control. In this study, we hypothesized that surface EMG recordings with high spatial resolution over reinnervated muscles could capture focal muscle activity and improve the classification accuracy of identifying intended movements. To test this hypothesis, TMR subjects with transhumeral or shoulder disarticulation amputations were recruited. Spatial filters such as single differential filters, double differential filters, and various two-dimensional, high-order spatial filters were used, and the classification accuracies for fifteen different movements were calculated. Compared with monopolar recordings, spatially localized EMG signals produced increased accuracy in identifying the TMR patients' movement intents, especially for hand movements. When the number of EMG signals was constrained to 12, the double differential filters gave 5-15% higher classification accuracies than the filters with lower spatial resolution, but resulted in comparable accuracies to the filters with higher spatial resolution. These results suggest that double differential EMG recordings may further improve the TMR-based neural interface for robust, multifunctional control of artificial arms.

Functional outcome of hip disarticulation and hemipelvectomy: a cross-sectional national descriptive study in the Netherlands.

OBJECTIVE: To describe characteristics of hip disarticulation and hemipelvectomy amputees, to assess their level of activities, participation and experienced limitations in mobility and to describe the amputation-related problems. DESIGN: A cross-sectional study. SETTING: Patients were mainly recruited via orthopaedic workshops in the Netherlands. SUBJECTS: Forty-six patients with an acquired unilateral hip disarticulation or hemipelvectomy at least one year post amputation. MAIN OUTCOME MEASURES: Sickness Impact Profile 68 (SIP 68) to assess the level of activity and participation and the questionnaire Rising and Sitting Down, Walking and Climbing Stairs to assess perceived limitations in mobility. RESULTS: The 46 patients (31 with hip disarticulation and 15 with hemipelvectomy) had a mean age of 55.8 years (SD 12.1). In 78% of cases the reason for amputation was a tumour. Mean SIP 68 was low, 10.5 (SD 6.9). Hip disarticulation amputees had significantly poorer emotional stability than the hemipelvectomy amputees (P = 0.04). All amputees experienced considerable limitations in their mobility according to the Rising and Sitting Down, Walking and Climbing Stairs scores. CONCLUSIONS: Hip disarticulation and hemipelvectomy amputees have a relatively high level of activity and participation (SIP scores) but at the same time experience limitations in walking, rising and sitting down and climbing stairs.