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Bilateral Amputation A Literature review Craig Evans June 2006.

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1 Bilateral Amputation A Literature review Craig Evans June 2006

2 The search begins… CATEGORYARTICLES Case studies (C) 2TT TT/TF 2TF 2UL Other 30 12 3 0 9 6 General inc. 2AMPs (G)24 2AMP focus (F)8 2AMP – UL13 Prosthetics16

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


6 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.”

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

8 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 2 nd hand modular components (Marzoug et al, 2003, G Abs). Ergometry (Vestering et al, 2005, G)

9 SCALES From Devlin et al (2004)From Kulkarni et al (1996)

10 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

11 COMPLICATIONS DVT/PE (Zickler et al, 1999, F) 26% of 2AMPs Immobile after 2 nd amputation Males Falls (Kulcarni et al, 1996, G) 27% (4) had falls Prostheses worn 2:2

12 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

13 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!”

14 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

15 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

16 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???

17 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

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

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

20 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

21 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)

22 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

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

24 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

25 Mobility Aides 4 footed vs 2 wheeled walkers (Tsai et al, 2003, G) WalkerSpeed (m/sec) FFW0.27 TWW0.5

26 Sitting balance Sitting balance Kirby and Chari, 1990 (G) Bilateral amputees Prostheses onProstheses offMean difference Straight forward Thigh support Ischial support 94.3 58.5 104.4 99.7 10.1* 41.2^ Anterolateral (45 degrees) Thigh support Ischial support 102.3 74.7 110.9 106.2 8.6 31.5^ * = p < 0.05, ^ = p < 0.0001

27 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)

28 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


30 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”

31 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

32 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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