Unilateral Above-knee Amputation Research Articles

1001 A Case Report on Popliteal Artery Occlusion After a Low-Energy Trauma Years After Total Knee Arthroplasty

Abstract Aim To highlight the significance of dislocated total knee arthroplasty, which is more likely to happen after a low-energy trauma and can result in limb-threatening neurovascular complications and compartment syndrome, we present a case of mild trauma that resulted in the co-occurrence of the occlusion of the left popliteal artery and vein 10 years after the implantation. Method Three weeks after a low-energy fall on her knee at home, a 69-year-old woman presented to our orthopedics clinic with swelling, paresthesia, and paralysis in her left leg. She had edema and significant ecchymosis, and the tibial pulses in her left knee had vanished. She had uneventful bilateral knee arthroplasty surgery on her right and left knees six and ten years ago, respectively. Her medical history is significant for type 2 diabetes mellitus and hypertension. Doppler ultrasound and CT angiography showed occluded popliteal artery and vein. Following thromboembolectomy by cardiovascular surgeons, orthopedic surgeons underwent lower leg preventative fasciotomy under general anesthesia by creating two longitudinal incisions on either side of the tibia. Results Doppler ultrasonography on the fifth follow-up day revealed biphasic flow in the posterior tibial artery and monophasic flow in the dorsal tibial artery, however, the paralysis and paresthesia were still present. Ultimately, unilateral above-knee amputation was performed. Conclusions Due to the high level of concern for vascular injury and compartment syndrome, we advise physicians to consider popliteal artery injury while treating patients who underwent total knee arthroplasty years ago and present with minimal trauma.

Symmetry Function: The Differences between Active and Non-Active Above-the-Knee Amputees.

The number of patients with unilateral above-knee amputation (AKA) due to non-vascular causes has remained stable over the years, at 0.92 per 1000 people per year. Post-AKA individuals are at risk of experiencing a higher incidence of chronic pain. Post rehabilitation, it is estimated that between 16–62% of patients with musculoskeletal disabilities fail to meet the minimum criteria for physical activity in comparison to a healthy population. The current study included 14 participants (11 men and 3 women) with a mean age of 46.1 ± 14.2 years, body height of 1.76 ± 0.09 m, and weight of 79.6 ± 18.3 kg, who were all post-unilateral above-the-knee amputees. Patients in the study were divided into two groups: active (AC) and non-active (NAC). This study was conducted in a certified Laboratory of Biomechanical Analysis using the BTS Smart-E system (BTS Bioengineering). In order to investigate the symmetry function (SF) of gait, the only measurements included were the time series assessment of gait variables defining pelvic and lower limb joint motion and ground reaction forces (GRF). Both groups had an asymmetrical gait pattern with a different magnitude and relative position in the gait cycle, which was revealed by SF. The differences in terms of median, minimum, and maximum were statistically significant (p < 0.05), with SF ranging from –25 to 24% for the AC group and from 43 to 77% (59% on average) for the NAC group. The AC’s pattern was more symmetrical compared to the NAC’s pattern, especially in the case of pelvic and hip joint motion.

Symmetry function in gait pattern analysis in patients after unilateral transfemoral amputation using a mechanical or microprocessor prosthetic knee

BackgroundAbove-knee amputations (AKAs) contribute to gait asymmetry. The level of asymmetry is affected by the type of knee prosthetic module. There is limited evidence suggesting that more technically advanced solutions (microprocessor modules; MicPK) are superior to less advanced ones (mechanical modules; MechPK). The study aimed to evaluate the variable range of hip and pelvic joint movements during gait and look for differentiating areas with an increased level of asymmetry of the gait cycle in individuals who underwent an AKA and are equipped with MicPK or MechPK.MethodsTwenty-eight individuals participated in the study; 14 were assigned to a study group of individuals who underwent a unilateral AKA, and the other 14 were healthy participants as a control group. The movement task was recorded using the optoelectronic SMART-E system following the standard Davis protocol (the Newington model). A new method of quantifying gait symmetry using the symmetry function (SF) is proposed. SF is an integral measure of absolute differences in time-standardized signals between sides throughout the whole cycle of motion variability.ResultsIn the frontal plane, there were significant differences between groups in the asymmetry of the range of movement in the hip joint of the intact limb. In the middle of the support phase, the intact limb was more adducted in individuals with MicPK and less abducted in people with MechPK (differences in mean 180%, p < 0.000; max 63%, p < 0.000; min 65%, p < 0.000). In the sagittal plane, the range of asymmetry of the flexion and thigh extension of the intact limb was similar to and only slightly different from the physiological gait. In the transverse plane, higher asymmetry values were noted for individuals with MicPK. In the final stage of the swing phase, the thigh was more rotated both externally and internally. The size of the asymmetry, when compared to gait of healthy individuals, reached 50% (differences in mean 115%, p < 0.232; max 62% p < 0.26; min 50, p < 0.154).ConclusionsIn the study group, the assessed ranges of pelvic and thigh movement in the hip joint differed only in the frontal plane. Individuals who underwent a unilateral above-knee amputation may gain less from using MicPK than anticipated.

Unilateral above-knee amputees achieve symmetric mediolateral ground reaction impulse in walking using an asymmetric gait strategy

The ability to sustain steady straight-ahead walking is one goal of gait rehabilitation for individuals with unilateral above-knee (UAK) amputation. Despite the morphological and musculoskeletal asymmetry resulting from unilateral limb loss, the mediolateral ground-reaction-impulse (GRI) should be counterbalanced between the affected and unaffected limbs during straight-ahead walking. Therefore, we investigated the strategies of mediolateral ground-reaction-force (GRF) generation adopted by UAK prosthesis users walking along a straight path. GRFs of 15 participants with UAK amputation were measured during straight-ahead walking. Then, the mediolateral GRI, stance time, and mean mediolateral GRF during the stance phase of the affected and unaffected limbs were compared. To better understand the GRF generation strategy, statistical-parametric-mapping (SPM) was applied to assess the phase-dependent difference of the mediolateral GRFs between two limbs. The results showed that UAK prosthesis users can achieve symmetric mediolateral GRI during straight-ahead walking by adopting an asymmetric gait strategy: shorter stance time and higher mean mediolateral GRF over the stance phase for the affected than for the unaffected limb. In addition, the analysis using SPM revealed that the affected limb generates a higher mean medial GRF component than the unaffected limb, especially during the single-support phase. Thus, a higher medial GRF during the single-support phase of the affected limb may allow UAK prosthesis users to achieve mediolateral GRI that are similar to those of the unaffected limb. Further insights on these mechanics may serve as guidelines on the improved design of prosthetic devices and the rehabilitation needs of UAK prosthesis users.

A kinematic and kinetic dataset of 18 above-knee amputees walking at various speeds

Motion capture is necessary to quantify gait deviations in individuals with lower-limb amputations. However, access to the patient population and the necessary equipment is limited. Here we present the first open biomechanics dataset for 18 individuals with unilateral above-knee amputations walking at different speeds. Based on their ability to comfortably walk at 0.8 m/s, subjects were divided into two groups, namely K2 and K3. The K2 group walked at [0.4, 0.5, 0.6, 0.7, 0.8] m/s; the K3 group walked at [0.6, 0.8, 1.0, 1.2, 1.4] m/s. Full-body biomechanics was collected using a 10-camera motion capture system and a fully instrumented treadmill. The presented open dataset will enable (i) clinicians to understand the biomechanical demand required to walk with a knee and ankle prosthesis at various speeds, (ii) researchers in biomechanics to gain new insights into the gait deviations of individuals with above-knee amputations, and (iii) engineers to improve prosthesis design and function.

Evaluation of Use of Prosthesis, Mobility, and Quality of Life in Young and Adult Persons with Unilateral Above-Knee Amputation 7 Years after the 2008 Sichuan Earthquake

ABSTRACT Background The 2008 Sichuan earthquake resulted in many casualties, also leaving a great number of persons with amputation who require long-term rehabilitation. Objectives This study aims to evaluate the use of prostheses, mobility, and quality of life and to determine factors associated with better rehabilitation outcomes 7 years after the earthquake for individuals from the StandTall rehabilitation program with traumatic unilateral above-knee amputation due to earthquake injuries. Method This is a cross-sectional study. Twenty-four individuals with unilateral above-knee amputation were recruited either at home visits or during clinic sessions between December 2014 and May 2015. Main outcome measures were 12-Item Short Form Survey Version 2, Amputee Mobility Predictor, Houghton Scale, and Trinity Amputation and Prosthesis Experience Scales. Results Adults with unilateral above-knee amputation experienced worse psychological adjustment to limitation (p = 0.018), more social activity restrictions (p = 0.072), and suffered from more residual limb pain (p = 0.024), and phantom pain (p = 0.044). Rehabilitation success was associated with less athletic restriction (p = 0.053), less functional restriction (p = 0.077), and greater prosthetic satisfaction (p = 0.085). Conclusions Adults with unilateral above-knee amputation experienced greater difficulties in psychological adjustment to limitation and social activities, even 7 years after the amputation. Residual limb and phantom pain were greatly affected by age. Prosthetic daily wearing time correlated with better functional outcome for individuals with unilateral transfemoral amputation. This study provides information regarding long-term rehabilitation outcomes of individuals with traumatic unilateral above-knee amputation. Age, daily prosthetic wearing time, and residual limb pain and phantom pain are main factors affecting rehabilitation outcomes of individuals with amputation. Physical quality of life and psychosocial quality of life are both impaired by amputation.

Long-term clinical evaluation of the automatic stance-phase lock-controlled prosthetic knee joint in young adults with unilateral above-knee amputation

Purpose: The purpose of this study was to clinically evaluate the automatic stance-phase lock (ASPL) knee mechanism against participants’ existing weight-activated braking (WAB) prosthetic knee joint.Method: This prospective crossover study involved 10 young adults with an above-knee amputation. Primary measurements consisted of tests of walking speeds and capacity. Heart rate was measured during the six-minute walk test and the Physiological Cost Index (PCI) which was calculated from heart rate estimated energy expenditure. Activity was measured with a pedometer. User function and quality of life were assessed using the Lower Limb Function Questionnaire (LLFQ) and Prosthetic Evaluation Questionnaire (PEQ). Long-term follow-up over 12 months were completed.Results: Walking speeds were the same for WAB and APSL knees. Energy expenditure (PCI) was lower for the ASPL knees (p = 0.007). Step counts were the same for both knees, and questionnaires indicated ASPL knee preference attributed primarily to knee stability and improved walking, while limitations included terminal impact noise. Nine of 10 participants chose to keep using the ASPL knee as part of the long-term follow-up.Conclusions: Potential benefits of the ASPL knee were identified in this study by functional measures, questionnaires and user feedback, but not changes in activity or the PEQ.Keywords: Amputee; artificial knee joint; energy expenditure; prosthesis; stance-phase control; transfemoral amputation, stance-phase control

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

To assess the effects of two types of microprocessor-controlled prosthetic knee joints (MPKs) on perceived performance and everyday life activity level. Randomized cross-over trial. Thirty persons with a unilateral above-knee amputation or knee disarticulation classified as Medicare Functional Classification Level-2. 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. 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. 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.

Poster 116: Bilateral Lower Extremity Atherosclerotic Embolic Painful Ulcerations with Unilateral Above-Knee Amputation: A Case Report

Poster 116: Bilateral Lower Extremity Atherosclerotic Embolic Painful Ulcerations with Unilateral Above-Knee Amputation: A Case Report

Predictors for institutionalization and prosthetic ambulation after major lower extremity amputation during an eight-year follow-up

Major lower extremity amputation (LEA) leads to great loss in mobility, exposing old people to the risk of losing their independent living status. This study applies predictors for institutionalization and considers prosthesis use by major lower leg amputees with peripheral arterial disease (PAD). 119 PAD patients admitted from home (mean age 73.6, SD 11.5 years, 48% men) underwent their first major LEA, 1998- 2002, and survived at least one month after the operation. Logistic regression analysis was run to clarify institutionalization predictors. Prosthesis use and ambulatory capacity were recorded during the follow-up. Older age, living alone, and unilateral above-knee amputation (AKA) or bilateral amputation predicted institutionalization. Of prosthesis users, 69% (27/39) were younger than 75 and 44% (17/39) were able to walk both in- and outdoors. Reasons for not receiving a prosthesis after amputation were: 1) short expected survival; 2) old age, combined with unilateral AKA or bilateral amputation; 3) unilateral AKA or bilateral amputation and a comorbid condition such as hemiparesis, paraplegia, uremia, dementia, or alcohol misuse. After one year, 72% (36/50) of amputees who were able to return home and 9% (3/32) of amputees in institutional care used a prosthesis. The majority of amputated patients cannot return home after their first LEA. Comorbid conditions particularly influencing functional capacity also hinder ambulation with a prosthesis.

Major lower extremity amputation in elderly patients with peripheral arterial disease: incidence and survival rates

The methods of treating peripheral arterial disease (PAD) have changed and become more prophylactic. This study describes and analyzes 1) the incidence rates of major lower extremity amputation (LEA) due to PAD, 2) occurrence of re-amputation, and 3) the survival of amputees and factors predicting survival. The series consisted of 210 patients (mean age 76.6, SD 10.7 yrs, 45.2% men) who underwent their first, i.e. index, major leg amputation because of PAD, in 1998-2002, in the city of Turku, Finland, population 175,000. The age-and gender-standardized incidence rate of combined above-knee and below-knee amputations was 24.1/100,000 person-years during 1998-2002. Thirty-four per cent of amputees underwent repetitive amputation. One-month mortality was 21% (n=45), one-year mortality 52% (n=109) and overall mortality 80% (n=168). Cardiovascular diseases predicted equally well 31-day, one-year, and overall mortality in age- and gender- adjusted analysis. Multiple co-morbidities (p=0.023) and unilateral above-knee amputations (p=0.047) were significant predictors for overall mortality in age- and gender-adjusted analysis. Cardiovascular diseases remained a significant predictor for 31-day and overall mortality in multivariate analysis (p=0.008 and p=0.015, respectively). Amputated patients' previous vascular procedures did not have any effect on mortality in the Cox model. Most revascularizations were performed less than six months before the index/first major LEA. Major LEAs seem to have been done late, and mainly for pain relief in the end-stage of patients with peripheral arterial disease.

Preliminary Evaluation of an Automatically Stance-Phase Controlled Pediatric Prosthetic Knee Joint Using Quantitative Gait Analysis

Andrysek J, Redekop S, Naumann S. Preliminary evaluation of an automatically stance-phase controlled pediatric prosthetic knee joint using quantitative gait analysis. Objectives To evaluate the effects on gait of a new pediatric prosthetic knee joint using an automatic stance-phase lock (ASPL), shown previously to help prevent falls, and to propose future design considerations and prosthetic alignments. Design Case series and crossover trial. Setting Human movement laboratory. Participants Three children with unilateral above-knee amputations and 3 children with bilateral above-knee or below-knee amputations. Interventions Not applicable. Main Outcome Measures Spatiotemporal, kinematic, and kinetic gait parameters. Results Spatiotemporal parameters indicated higher gait velocities with the ASPL knee joint for the children with unilateral amputations. The increased speed, as expected, was associated with increased temporal interlimb asymmetry, joint moments and powers, and excessive prosthetic knee range of motion in swing. A trend toward increased pelvic motions was observed with ASPL knee when compared with conventional knees. Conclusions The biomechanic performance of the single-axis ASPL knee joint was shown to be comparable with more complex polycentric pediatric prosthetic knee joint technologies worn by the children in this study.

Results of lower extremity amputations in patients with end-stage renal disease

Purpose: The purpose of this study was to determine the impact of end-stage renal disease (ESRD) on the outcome of patients undergoing lower extremity (LE) amputation.Methods: Hospital charts and vascular surgery registry data were reviewed for all patients who underwent LE amputation over a consecutive 56-month period. The results of 84 patients with ESRD (137 amputations) were compared with 375 patients (442 amputations) without ESRD.Results: Hospital mortality rate was significantly greater in patients with ESRD than patients without ESRD, 24% versus 7% (p = 0.001). Patients with ESRD undergoing minor amputations had mortality rates three times greater than patients without ESRD undergoing major LE amputations. In patients with ESRD requiring bilateral or unilateral above-knee amputation hospital mortality rates were 43% and 38%, respectively. In addition, patients with ESRD were seven times more likely to undergo bilateral amputation than patients without ESRD over a mean follow-up period of 17 months. No kidney transplant patients died after amputation.Conclusion: ESRD has a profound negative impact on morbidity, mortality, and survival rates after LE amputation. Attempts at prevention of amputation with aggressive foot care and patient education in this high-risk group should be the focus of therapy.

The relationship between comfortable and most metabolically efficient walking speed in persons with unilateral above-knee amputation

Walking is most efficient when the least energy is spent over a certain distance. In six normal male subjects and 11 males with above-knee amputation the comfortable self-selected walking speeds and the most metabolically efficient walking speeds were determined. For that purpose energy expenditure was measured per second and per meter at six incremental walking speeds. Heart and step rate were registrated also at each walking speed. The results showed that in subjects who have not undergone amputation the comfortable walking speed is the same as the most efficient walking speed. However, in the above-knee amputee group, the comfortable walking speed is lower than the most efficient walking speed. When both groups walked at their own efficient walking speed they had the same energy expenditure per second.

Factors influencing reintegration to normal living after amputation.

This study identified factors affecting reintegration to normal living (RNL) after lower extremity amputation. A questionnaire was used to evaluate RNL at a veterans' medical center and private rehabilitation clinic. The patients were 42 elderly individuals (68 +/- 1.5 years). Eighty-eight percent were men and 76% had additional health problems. Unilateral below-knee amputations, unilateral above-knee amputations, and bilateral amputations accounted for 38%, 36%, and 26% of subjects, respectively. Eleven questions were asked to evaluate mobility, self-care, work, recreation, social activities (daily functioning), relationships, social self, and life events (perception of self). The median overall RNL score was 16 of 22 (range, 5 to 22). Poor reintegration occurred in community mobility, work, and recreation. Perception of self questions showed satisfactory reintegration. Examination of variables impacting reintegration showed only additional illness significantly reducing the RNL score. It was concluded that current rehabilitative efforts regarding home mobility and psychological adjustment are satisfactory. More attention to community mobility, recreation, and additional illnesses would improve RNL after amputation.