Bilateral Amputation Research Articles

Management of intertrochanteric fracture in a bilateral below knee amputee

<p class="abstract">Intertrochanteric fracture in a patient with bilateral below knee amputation is rare and the management is challenging. The major difficulty is in applying optimal amount of traction for reduction of the fracture due to absence of foot. We present the case of an elderly female with bilateral below knee amputation presenting with a minimally displaced right intertrochanteric fracture. The patient was managed using reverse boot technique for applying traction, obtaining reduction and fixed with right proximal femoral nail. The patient was able to return to her pre-injury mobility status on the third postoperative day. We highlight a method of traction application using this simple modification of the fracture table so that adequate amount of traction can be applied safely.</p>

Effect of Amputation Level on Quality of Life and Subjective Function in Children.

Our aim was to discern whether children with amputations have differences in subjective function based on amputation level. We hypothesized that children with more proximal amputations would report poorer function and quality of life. An IRB-approved, retrospective chart review of patients aged 0 to 21 years old with lower extremity amputations was performed. Demographic information, type of amputation, type of prosthesis, and the Pediatric Outcomes Data Collection Instrument (PODCI) was collected from parents and children (above 10 y old). Patients were divided into 4 groups based on the level of amputation (ankle; transtibial; knee; transfemoral), and PODCI scores were compared between groups. PODCI subscores were also compared between unilateral versus bilateral amputations, high-demand versus low-demand prostheses, and congenital versus acquired amputations. We identified 96 patients for analysis (39 ankle, 21 transtibial, 27 knee, and 9 transfemoral amputations). The sports/physical functioning subscale of the PODCI showed the only statistically significant difference between amputation level and outcome with ankle-level amputations reporting higher scores than knee-level amputations (parent: 78.3±16.4 vs. 60.0±25.3, P=0.006; child: 87.4±15.3 vs. 65.4±31.5, P=0.03). Although not significantly different from either the ankle, knee, or transfemoral groups, patients with transtibial amputations reported intermediate scores (parent: 68.5±27.5; child: 78.9±25.5). There were no significant differences among amputation level for PODCI transfers, pain/comfort, global function, or happiness subscales. In subgroup analysis, same-level congenital amputees had similar scores to acquired amputees (P>0.05). When compared with unilateral knee amputations patients, patients with bilateral knee amputations had significantly worse transfer (62.4 vs. 88.3; P=0.02), sports/physical functioning (34.2 vs. 66.2; P=0.01), and global domains (58.4 vs. 80.5; P=0.02). Subjective sports and physical functioning of pediatric amputees were significantly worse after knee amputation when compared with ankle-level amputations. Although not statistically significant at all levels, our data suggest a graded decline in sports/physical functioning with higher level amputations. Amputation level did not affect pain, happiness, or basic mobility. Level III.

Anthropomorphism Index of Mobility for Artificial Hands.

The increasing development of anthropomorphic artificial hands makes necessary quick metrics that analyze their anthropomorphism. In this study, a human grasp experiment on the most important grasp types was undertaken in order to obtain an Anthropomorphism Index of Mobility (AIM) for artificial hands. The AIM evaluates the topology of the whole hand, joints and degrees of freedom (DoFs), and the possibility to control these DoFs independently. It uses a set of weighting factors, obtained from analysis of human grasping, depending on the relevance of the different groups of DoFs of the hand. The computation of the index is straightforward, making it a useful tool for analyzing new artificial hands in early stages of the design process and for grading human-likeness of existing artificial hands. Thirteen artificial hands, both prosthetic and robotic, were evaluated and compared using the AIM, highlighting the reasons behind their differences. The AIM was also compared with other indexes in the literature with more cumbersome computation, ranking equally different artificial hands. As the index was primarily proposed for prosthetic hands, normally used as nondominant hands in unilateral amputees, the grasp types selected for the human grasp experiment were the most relevant for the human nondominant hand to reinforce bimanual grasping in activities of daily living. However, it was shown that the effect of using the grasping information from the dominant hand is small, indicating that the index is also valid for evaluating the artificial hand as dominant and so being valid for bilateral amputees or robotic hands.

Technique for Rapid Hand Transplant Donor Procurement Through the Elbow.

Background: Hand and distal forearm allotransplantation has advanced over the last 20 years from experimental to a viable treatment option for bilateral upper extremity amputation. Despite widespread growth of this field, there are few technical reports that elaborate the details of donor arm procurement. This article details a technique for rapid donor procurement through the elbow for mid to distal forearm-level hand allograft procurement. Methods: Nine arm procurements were performed on deceased tissue-only donors provided by the local organ procurement organization, including two bilateral and five unilateral cases. Technique highlights include using a fishmouth incision through the lateral and medical epicondyles, identification of the neurovascular structures, and disarticulating the elbow joint. Results: Procuring through the elbow provides straightforward anatomy, bypasses the need to cut through bone, and allows tissue allotransplantation teams to achieve procurement, flushing, and packaging within 20 minutes. Conclusions: Procurement through the elbow is a simple procedure that streamlines the process for multi-organ donors by minimizing the time needed for hand allograft procurement. Team coordination and surgical rehearsals are essential for successful hand and upper extremity procurement and allotransplantation.

Avaliação da porcentagem de gordura corporal em um indivíduo com amputação transfemoral bilateral por diferentes métodos

A amputação predispõe a um risco de alterações na composição corporal, condição que interfere no equilíbrio no uso da prótese, aumenta o cansaço físico e tem como consequência menor rendimento nas terapias físicas. Nesse sentido, é fundamental eleger o método mais apropriado para avaliar a composição corporal. Objetivo: Avaliar a porcentagem de gordura corporal em um indivíduo com amputação transfemoral por diferentes métodos. Método: Trata-se de um estudo de caso de caráter clínico retrospectivo com um participante do sexo masculino, idade 67 anos com amputação transfemoral bilateral por insuficiência vascular, atendido pelo Serviço de Nutrição do Instituto de Medicina Física e Reabilitação do Hospital das Clínicas da Faculdade de Medicina da Universidade de São Paulo - IMREA HCFMUSP. Utilizou-se o somatório das dobras cutâneas, absorciometria de raio-X de dupla energia (DXA) e análise de impedância bioelétrica (IB). Resultados: Os dados antropométricos apontaram porcentagem de gordura corporal de 34,3%, a IB 33% e o DXA revelou 37%. Conclusão: Para este caso, sugere-se que na inviabilidade de avaliar a porcentagem de gordura corporal em indivíduos com amputação com o DXA, o somatório das dobras é o método elegível. Estudos futuros são imprescindíveis a fim de estabelecer o método adequado para avaliação da composição corporal de pessoas com amputações bilaterais de membros inferiores, tendo em vista que este resultado contribui para o melhor desfecho clínico de pacientes em processo de reabilitação.

Patient perspectives on benefits and risks of implantable interfaces for upper limb prostheses: a national survey

ABSTRACTObjective: Patient perspectives on benefits and risks of implantable interfaces for prostheses are needed.Methods: A telephone survey was administered to 808 Veterans. Multivariate logistic regression identified factors associated with willingness to consider surgery to restore touch and better movement control. Risk and benefit ratings were compared.Results: 41.8% of unilateral and 40.6% of bilateral amputees were willing to consider surgery for touch; 49.0% were willing to consider surgery for control. Persons 65–75 years and >75 were 0.42 (p= 0.0009) and 0.19 (p< 0.0001) as likely as those 18–45 to consider surgery for touch, those with better mental health (MH) were 0.47 (p= 0.0005) as likely as those with worse, and those with infection etiology were 1.7 (p= 0.03) as likely as those without. Persons 65–75 and >75 were 0.28 and 0.12 as likely as those 18–45 to consider surgery for control (p’s<0.0001). Myoelectric users were 2.16 (p= 0.006) as likely as body-powered users and persons with better MH were 0.61 (p= 0.03) as likely as those with worse to consider surgery for control. Long-term risks were most unacceptable. Durability, comfort, and improved functional abilities were most important.Conclusions: There is substantial interest in prosthetic interfaces to gain a sense of touch and greater movement control.

Patient Perspectives on Osseointegration: A National Survey of Veterans with Upper Limb Amputation.

Osseointegrated (OI) prostheses have a unique benefit-risk profile among prosthetic alternatives and have been marketed in the United States under a Humanitarian Device Exemption since 2015. Information about upper limb prosthesis user perspectives on benefits and risks, prosthesis-user subpopulations for whom OI is most acceptable, and outcomes that matter most to patients could help inform clinical and regulatory decision-making. Recent 21st Century Cures legislation expanded the role of patient experience data in the decision-making process of the U.S. Food and Drug Administration, recognizing that patient perspectives may be informative to regulators. To better understand prosthesis user perspectives about the benefits and risks associated with upper limb OI prostheses. Patient perspective survey. Telephone administration. National sample of veterans with upper limb loss. NA MAIN OUTCOME MEASURES: Benefit-risk survey developed for this study. Twenty-eight percent of unilateral and 13% of bilateral amputees were willing to consider osseointegration surgery. Multivariate logistic regression models [OR; 95% CI] showed that transhumeral amputation level [OR 1.40; 1.01-1.98] was associated with greater willingness to consider surgery, whereas older age [OR 0.17; 0.09-0.32] and higher VR-12 Mental Component Summary [OR 0.53; 0.35-0.81] were associated with less willingness. Having a durable/reliable device, the ability to do more activities, and having a comfortable device were rated as very important or somewhat important by 98% or more for every risk condition. Persons who were older, had transradial amputation (compared to transhumeral), and those who had better mental functioning were less willing to consider this surgery. Respondents who were willing to consider surgery indicated that the most important potential benefits were obtaining a durable/reliable device, the ability to do more activities, and having a comfortable device. Most were willing to accept one or more risks of surgery, with long-term risks including chronic pain, loss of nerve function, or device failure considered the most unacceptable. III.

Risk Factors for Falls in Individuals With Lower Extremity Amputations During the Pre-Prosthetic Phase: A Retrospective Cohort Study.

Falls in individuals with lower limb amputations (LLAs) pose significant health concerns. The literature is limited regarding falls during the preprosthetic phase of rehabilitation for persons with LLAs. To determine the incidence of falls and identify factors associated with falls during the preprosthetic recovery phase. Retrospective chart audit. Inpatient rehabilitation program. Four hundred forty individuals with LLAs (age ± SD = 61.93 ± 14.53 years, 73.18% male) who attended inpatient rehabilitation from 26 July 2011 to 21 August 2017. Not applicable. The number of self-reported falls was recorded from the time of surgery to admission for inpatient rehabilitation. Outcomes of interest were any fall (1+ fall) and recurrent falls (2+ falls). A retrospective chart audit was performed on consecutive admissions to an inpatient rehabilitation program. The incidence of falls was 8.37 per 1000 patient-days. Falls were sustained by 60.9% of the sample. Unilateral transtibial amputation was independently associated with an increased risk of recurrent falls (relative risk [RR] 1.59, 95% confidence interval [CI] 1.13-2.23, P = .008). Diabetes mellitus was independently associated with an increased risk of any fall (RR 1.18, 95% CI 1.01-.38, P = .03). Finally, bilateral transtibial amputation was independently associated with a reduced risk of any fall (RR 0.59, 95% CI 0.39-0.90, P = .014). Consistent with the current literature, diabetes mellitus and a unilateral transtibial amputation were risk factors for falling, whereas a bilateral transtibial amputation and increasing age presented new findings as factors associated with decreased falling. III.

Prosthetic Limb User Experiences With Crossover Feet: A Pilot Focus Group Study to Explore Outcomes That Matter

ABSTRACT Introduction Many different prosthetic feet are available to meet the diverse needs of people with lower-limb amputation. Current methods used to assess comparative effectiveness of prosthetic feet may not align with outcomes that are most important to people with lower-limb amputation. User participation in qualitative research is one approach to guide selection of outcome measures for clinical practice and quantitative research studies. This pilot study examined outcomes of importance to people who have used both energy storing and crossover prosthetic feet. Materials and Methods An in-person focus group of people with lower-limb amputation was conducted. Inclusion criteria were as follows: 18 years of age or older, lower-limb amputation, previous use of an energy storing foot and crossover foot, and a minimum of 1 year prosthesis use. Results Five participants with lower-limb amputation (4 males/1 female), aged 41 to 59 years (mean, 45.6 ± 7.7 years), participated in the focus group. Three participants had unilateral transtibial amputations; one had bilateral transtibial amputations; and another had bilateral involvement with a transtibial and partial-foot amputation. All participants reported daily use of a prosthesis (mean, 15.2 ± 1.1 hours). Three categories of themes arose from this focus group: direct outcomes, external influences, and indirect outcomes. Direct outcomes included balance and stability, endurance and sustained gait quality, and naturalness. External influences included peer and prosthetist interactions. Indirect outcomes included increased confidence and expanded mobility. Outcome measures available to assess identified constructs were suggested. Conclusions Engagement of prosthesis users through qualitative research methods can inform the choice of outcome measures used to assess clinical outcomes or evaluate the effectiveness of prosthetic devices.

Clinical and demographic characteristics of patients with lower limb amputation

Aim: Lower limb loss affects an individual’s ability to stand, transfer, and ambulate. The aim of this study is to assess clinical and demographic characteristics of patients with lower limb amputation.Materials and Methods: Our study is a retrospective cohort study. 836 patients with lower limb amputation applied to our hospital between January 2012 and May 2013 were included in this study. Demographic and clinical characteristics of patients were reviewed and saved from patient’s folder. Descriptive variables were shown as mean±standard deviation(min–max). And categorical variables were shown as the number of cases (n%).SPSS software Version 15.0 was used in the evaluation of the data.Results: The mean age of total 836 lower limb amputees was 36.12±11.69 years (9-78). The percentage of unilateral amputation was 770(92.3%) and bilateral lower limb amputation was 59(7.1%). According to the level of amputation, 456(54.5%) of the patients had unilateral above-knee, 236(28.3%) had unilateral below-knee amputation. For etiology, we found that 373(44.6%) of them were traffic accidents, 103(12.5%) occupational accidents. The majority of patients 456(54.5%) were ambulated microprocessor-controlled above-knee prosthesis and then below-knee prosthesis with active vacuum system 224(26.7%).Conclusion: Although trauma is recognized to be the most common cause of amputation among applying amputees, we think that those amputees do not reflect the general profile in our country but that it is instructive with regard to the features of amputees. This data is important for the community rehabilitation of amputees and the development of new prosthetics.

A national study of Veterans with major upper limb amputation: Survey methods, participants, and summary findings.

IntroductionA comprehensive study to assess quality and outcomes of care for Veterans with upper limb amputation is needed. This paper presents methods and summary findings from a national survey of Veterans with upper limb amputation.MethodsAfter completion of a pilot study to develop and refine methods, computer-assisted telephone interviews were conducted with 808 Veterans with upper limb amputation (response rate = 47.7%; cooperation rate = 63.3%).ResultsRespondents were 776 unilateral and 32 bilateral amputees, 97.5% male, mean age 63.3 (sd 14.1). Prostheses were used by 60% unilateral and 91% bilateral, the majority used body powered devices. Prostheses were used ≥8 hours/day by 52% unilateral and 76% bilateral. Prosthetic training was received by 71% unilateral and 59% bilateral. Mean prosthetic satisfaction was 3.9 (sd 0.6) and 3.8 (sd 0.7) as measured by TAPES; and 25.0 (sd 5.1) and 25.7 (sd 4.5) as measured by OPUS CSD for unilateral and bilateral respectively. Mean perceived disability (measured by QuickDASH) scores were 49.5 (sd 20.7) for unilateral and 34.7 (sd 22.0) for bilateral. VR-12 PCS scores were below population norms. The majority reported contralateral limb pain, musculoskeletal conditions, back and neck pain. Phantom limb pain was reported in 83.4% of unilateral and 68.8% of bilateral, and residual limb pain in 65.1% of unilateral and 68.8% of bilateral. Most, (81.8% unilateral, 84.4% bilateral) had been to a Veterans Affairs medical center (VA) for amputation care, while 57% of unilateral and 81.3% of bilateral had been to a VA amputation clinic.Discussion/ConclusionVeterans with upper limb amputation have moderately impaired physical functioning. Prosthesis use rates were lower than previously reported. Although satisfied with their prostheses, nearly half used them ≤8 hours/day. Rates of musculoskeletal problems, phantom and residual limb pain were higher than previously reported. A substantial proportion never received prosthetic training, or VA amputation care.

Amputation Evaluation: Sixth Edition Approaches

Abstract Upper extremity amputations are rated in the AMA Guides to the Evaluation of Permanent Impairment (AMA Guides), Sixth Edition, Section 15.6, Amputation Impairment, where text, tables, and figures guide evaluators in combining proximal diagnosis-based impairments (DBIs) and proximal range-of-motion impairments. The AMA Guides provides impairment grids for lower and upper extremity amputations, which are divided into five impairment classes (0 through 4), and each impairment class is further divided (except class 0) into five grades (A through E), each with its respective impairment rating that is expressed as a percentage of the extremity. Determining impairment class, and thus the default value of impairment, is straightforward if the amputation occurred directly at one of the points in the relevant grid; if the amputation occurred at another point, the evaluator should consult the appropriate figure to assess how the specific level of amputation corresponds with impairment percentages. An individual's proximal problems may lead to an increase in the impairment value because of the application of grade modifiers. Except in rare instances of bilateral upper extremity amputation or when the patient is unable to wear a prosthesis for a lower extremity amputation, the evaluator usually uses the default rating value within the selected impairment class as the final percentage rating. Evaluators are advised to re-read the amputation section in the AMA Guides before conducting an amputation evaluation.

Self-reported Functional Status in US Service Members After Combat-Related Amputation.

The objective of this study was to describe the functional status of US service members after combat-related amputation. This was a cross-sectional analysis of data from a subsample of the Wounded Warrior Recovery Project, an ongoing, web-based, longitudinal examination of patient-reported outcomes of injured service members. The study sample included 82 Wounded Warrior Recovery Project participants with a combat-related lower extremity amputation who reported using a prosthetic device and completed the Orthotics and Prosthetics Users' Survey Lower Extremity Functional Status, which measures self-reported functional status in participants with a prosthetic device. Basic activities, such as walking indoors, getting on and off the toilet, and getting up from a chair, were reported by the majority of participants as "very easy/easy," whereas higher-level activities, such as climbing stairs, walking long distances, or running, were more often reported as "slightly difficult/very difficult" or "cannot do this activity." Functional status varied significantly by amputation site (unilateral below knee, unilateral above knee, or bilateral; P = 0.004), with significantly better function reported in those with unilateral below knee than bilateral amputation (P < 0.05). These findings highlight deficits in the functional status of US service members with combat-related amputation. Self-reported functional status of daily activities may help target important activities for patient-centered goals.

Athletes With Versus Without Leg Amputations: Different Biomechanics, Similar Running Economy.

Athletes with transtibial amputations use carbon-fiber prostheses to run. Compared with biological legs, these devices differ in structure and function, and consequently yield affected leg running biomechanics that are theoretically more economical than those of nonamputees. However, experimental data indicate that athletes with unilateral and bilateral transtibial amputations exhibit running economy values that are well within the range of nonamputee values.

The Estimation of Indicated Energy Amount and Drug Therapy in an Obese Patient With Type 2 Diabetes Following Bilateral Transfemoral Lower Limb Amputation

The Estimation of Indicated Energy Amount and Drug Therapy in an Obese Patient With Type 2 Diabetes Following Bilateral Transfemoral Lower Limb Amputation

Oral Hygiene Management by Dental Hygienists for a Patient with Blindness and Bilateral Forearm Amputation Because of Severe Extensive Burns: A Case Report

Oral Hygiene Management by Dental Hygienists for a Patient with Blindness and Bilateral Forearm Amputation Because of Severe Extensive Burns: A Case Report

FUNCTIONAL DIFFERENCES OF BILATERAL TRANSFEMORAL AMPUTEES USING FULL-LENGTH AND STUBBY-LENGTH PROSTHESES.

Many unilateral amputations are followed by a contralateral amputation within three years, sometimes presenting as bilateral transfemoral amputations. Bilateral transfemoral amputees that successfully use prostheses are an understudied patient population. This study establishes reference values for this population in users of short non-articulating (stubby) or full-length articulating prostheses. Anthropometric and demographic information was collected from participants. Additionally, participants completed a self-reported Prosthesis Evaluation Questionnaire-Mobility Subscale 12/5 (PEQ-MS) and performed multiple physical mobility tests, including walking tests and the multi-directional Four Square Step Test (FSST). Full-length users rated their abilities to complete the PEQ-MS tasks as less difficult than stubby users in eight of the 12 items. Gait analysis revealed a greater amount of time is spent in stance phase with a greater portion in double limb support for both user groups, and a greater percentage in stance phase for the subject-reported dominant limb. Stubby users' gait velocity had a significant reduction from that of their full-length peers; however, cadence was similar between groups. Both user groups completed the FSST at comparable times. These outcomes may be of benefit for identifying tasks bilateral transfemoral prosthetic users may find to be most difficult as well as for identifying normal ambulation patterns within this population. Future studies with a greater number of subjects would enable these results to be further generalized.

Thumb Amputations in Children: Classification and Reconstruction by Microsurgical Toe Transfers

Traumatic amputations of the thumb are rare in children compared with adults, but hand surgeons remain reticent to consider microsurgical reconstruction with toe-to-thumb transfers. This study reports the functional outcomes and complications of children with traumatic thumb amputations who underwent toe-to-thumb reconstruction. A retrospective review of children who sustained thumb amputations and whose parents elected for their child to undergo reconstruction by toe-to-thumb transfer was performed. Details of the level of thumb amputation, whether other fingers were also amputated, which toe was transferred on which vascular pedicle, survival of the transfer, and complications, were collected. Opposition, sensation, and growth of the toe-to-thumb transfers was measured. Functional and psychosocial outcomes were evaluated by both the parents and the older children using the Pediatric Outcomes Data Collection Instrument questionnaire. Twenty-one thumb amputations in 19 children between the ages of 2 and 17 years were referred for secondary reconstruction. Ten were isolated thumb amputations and 11 were combined thumb and multiple finger amputations. Two children had bilateral thumb amputations. Twenty-one toe-to-thumb transfers were performed: 14 second toe transfers and 7 great toe transfers (3 great toe and 2 trimmed and 2 Morrison wraparound variations). There were no immediate postoperative reexplorations of the microsurgical anastomoses and all toe transfers survived completely. All children regained pinch and grasp function and sensation. There were no gait problems in the donor feet. Microsurgical toe-to-thumb transfers should be offered as an alternative option to the traditional techniques of distraction lengthening and pollicization, for posttraumatic thumb reconstruction in children for any level of amputation from just distal to the carpometacarpal joint to the interphalangeal joint. Toe-to-thumb transfer provides length, opposition, and sensation without disturbing ambulation and is associated with excellent psychosocial outcomes as evaluated by both parents and older children. Therapeutic IV.

High Bilateral Amputations and Dismounted Complex Blast Injury (DCBI).

High, combat-related bilateral lower extremity amputations rarely occur in isolation. Dismounted complex blast injury is a devastating and life-threatening constellation of multisystem injuries most commonly due to dismounted contact with improvised explosive devices. Rapid damage control resuscitation and surgery are essential to improve patient survival and minimize both early complications and late sequelae. A coordinated team approach is essential to provide simultaneous airway management, volume resuscitation (ideally with whole blood or ratio transfusion), and immediate control of life-threatening hemorrhage. Temporary aortic or iliac vessel clamping during concurrent exploratory or vascular control laparotomy is frequently required. Stabilization of unstable pelvic fractures is then performed, followed by debridement and irrigation of all wounds, which should be left open, and subsequent provisional stabilization of long bone fractures. The goal of the initial surgical resuscitative endeavor is rapid concurrent control of all sources of hemorrhage to avoid the lethal triad of acidosis, hypothermia and coagulopathy. To this end, multiple surgeons or surgical teams should be utilized whenever feasible. Patients then require ongoing resuscitation followed by early and frequent return to the operating suite throughout the evacuation chain. Utilizing this approach, a high survival rate with reasonable functional outcomes is achievable despite the extreme severity of the DCBI pattern.

Poster 177: Alternative Options for Anticoagulation in a Prothrombotic, Bilateral above Knee Amputee with Life-Threatening Reactions to Standard Anticoagulants

Poster 177: Alternative Options for Anticoagulation in a Prothrombotic, Bilateral above Knee Amputee with Life-Threatening Reactions to Standard Anticoagulants