Transfemoral/Transtibial patient prognosis predictors Hannah Chaney ~ Sara Patterson

Stats 54% amputations due to vascular disease 45% due to trauma <2% due to cancer Odds of death are 2.3X higher with hx of cerebrovascular disease within a year Nearly half of amputations with vascular disease will die within 5 years Odds of death are 3.5x higher with renal disease within a year Of people with LE amputation up to 55% will require an additional amputation of the second leg within 2-3 years

Transfemoral Amputation (AKA) Average 29,607 performed annually ⅕ people with limb loss have AKA Less metabolically efficient than BKA Due to trauma, cardiovascular/resp disease,malignancies, diabetes Good prognosis for people <65 y/o and without Cardiovascular disease Patient: it was 10X more difficult with AKA than BKA Smith, D. Amputee Coalition, 2004

In a 16 y/o pt with bone cancer, does a transfemoral amputation provide a better quality of life than a limb salvage procedure? (if possible) Long term survivorship & osteosarcoma: 12-24 years later filled out functional assessment, quality of life assessment, body image assessment,self esteem assessment & social support assessment Better leg function was significantly related to better emotional functioning Rotationplasty had higher function, less pain, and more involvement in hobbies, work, social settings Robert, R. Pediatric Blood and Cancer, 2010

Complex limb salvage or Early Amputation for Severe Lower-limb injury: A Meta- analysis of observational studies Was based off of Injury not malignancy 9 observational studies Length of hospital stay, pain & return to work time is similar Limb salvage procedure: slightly lengthier rehab, more costly, more surgeries, increased re-hospitalizations At time of injury pt prefer limb salvage, however pt who had failed salvage say they would have opted for an amputation instead Busse, J., Journal of Orthopaedic Trauma, 2007

TransTibial Amputation (BKA) Lower Limb amputation, 10-12 cm below tibial tuberosity Due to trauma or disease (Peripheral Vascular Disease, Diabetes, Infection, Foot Ulcer, Tumor) Historically increased in amount of this type of amputation Doppler blood-flow detection equipment Studies showing more successful rehab LE Prosthetics In Class Slides Moving Forward, 2013

Biomechanical adaptations of transtibial amputee sprinting in athletes using dedicated prostheses People with a BKA have ran over 100m in little over 11 s Many athletes train as much as their able-bodied counterparts Benefit of training and sprint performance are affected by the design of the prosthesis Flex-Foot Modular III - up on toes gait for sprinting lead to prosthetic limb kinematics Major compensatory mechanisms=increased stance phase hip work on the prosthetic limb, increased hip and knee work on the intact limb during swing Buckley, J. G. Clinical Biomechanics, 2000.

Goals of the Study Determine the biomechanical adaptations in two transtibial amputee sprinters by determining the joint movements, muscle powers and the work done by the musculature at the ankle, knee and hip of the prosthetic and sound limbs To examine the effect of dedicated prosthetic design upon these adaptations by comparing prosthetic limb kinetics when subjects used a Sprint Flex and Cheetah prosthesis Buckley, J. G. Clinical Biomechanics, 2000.

Methods Two subjects - both had competed at all levels including World and Paralympic Games Sprint Flex Modular III (Sprint Flex) vs. Sprint Flex Modular IV (Cheetah) Two trials - one for each prosthetic; subjects repeated maximal sprint trials Calculations: Moments, muscle powers and the mechanical work done at the joints of the prosthetic and sound limbs Buckley, J. G. Clinical Biomechanics, 2000.

Results Joint kinetics from single ground contact while sprinting Differences in joint kinetics of each subject leads to differences of favored prostheses From the two subjects, the study suggests that there is increased hip work on the prosthetic limb However, there is also additional compensation found with increased work at the residual knee. Provided insight into the biomechanical adaptations needed to obtain speed during full speed sprinting and the mechanical behavior of the prostheses used Buckley, J. G. Clinical Biomechanics, 2000.

What Can Physical therapists DO? Prior to Surgery Exercises for conditioning, improvement in strength and flexibility Educate the patients on how to walk with a walker or crutches, rolling in bed, sitting and transfers for after surgery Educate on what to expect after the procedure After Surgery Stretching, ROM Exercises Educate how to roll in bed, transfers Educate how to position surgical limb to prevent contractures Educate about using a wheelchair, stand and walk with a AD Educate about swelling and compression Pain Management Moving Forward, 2013

References Buckley, J. G. (2000). Biomechanical adaptations of transtibial amputee sprinting in athletes using dedicated prostheses. Clinical Biomechanics,15(5), 352-358. Busse J, Jacobs C, Swiontkowski M, Bosse M, Bhandari M. Complex Limb Salvage or Early Amputation for Severe Lower-Limb Injury: A Meta-Analysis of Observational Studies. Journal of Orthopaedic Trauma. 2007;21(1):70-76. doi:10.1097/bot.0b013e31802cbc43. Moving Forward. Physical Therapy Brings Motion to Life. American Physical Therapy Association. December, 2013. LE Prosthetics, In Class Slides, July 2016. Robert R, Ottaviani G, Huh W, Palla S, Jaffe N. Psychosocial and functional outcomes in long-term survivors of osteosarcoma: A comparison of limb-salvage surgery and amputation. Pediatr Blood Cancer. 2010:n/a-n/a. doi:10.1002/pbc.22419. Smith D. The Transfemoral Amputation Level, Part 1 | Amputee Coalition. Amputee-coalitionorg. 2016. Available at: http://www.amputee-coalition.org/resources/transfemoral-amputation-part-1/. Accessed July 11, 2016.

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