1. Bilateral Amputation A Literature review
Craig Evans
June 2006

2. The search begins… CATEGORY ARTICLES Case studies (C) 30
2TT
TT/TF
2TF
2UL
Other 30 12 3 9 6
General inc. 2AMPs (G) 24
2AMP focus (F) 8
2AMP – UL 13
Prosthetics 16
Search (CIAP: CINAHL database )
Amputee or amputation
Bilateral
[Human studies]
83 results – 62 were relevent

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
Carrington et al (2001). “A foot care program for diabetic unilateral lower-limb amputees.” Diabetes Care, Feb, 24(2):
“…this study was designed to examine the efficacy of a focused foot care program for diabetic unilateral amputees in preventing amputation of the contralateral limb.”
The foot care program was unable to significantly reduce the bilateral amputation rate in diabetic unilateral amputees.
The study emphasized “ the need for the prevention or reversal of PVD in people with diabetes.” An aggressive wound care protocol +/- revasculaization can help heal chronic ulcers and save limbs.
One of the problems with this foot care program was the limited follow up and that patients continuing foot care was in their local districts.
“The finding of significant difference in skin CO2 levels between the bilateral and unilateral diabetic amputees studied here requires further investigation.
“PVD is more closely associated with diabetic bilateral amputation than neuropathy or level of foot care knowledge.”

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
Mueller et al (1995). “Incidence of skin breakdown and higher amputation after transmetatarsal amputation: implications for rehabilitation.” Archives of Physical Medicine and Rehabilitation, Jan, 76(1): 50-4.
Descriptive data collection of 120 transmetatarsal amputees (?prospective vs. retrospective?)
12% had bilateral TMAs – there were no definitive conclusions relating specifically to bilateral TMAs
TMAs are :
At high risk of skin breakdown (27%) or higher amputation (28%) especially in the 1st 3 months. “The first 3 months after surgery is the time when patients are becoming ambulatory, and may inadvertently injure their foot or surgical incision site during weight-bearing activities.
Acute care should protect the residuum – total contact casting, clam shell orthotic, cam walker?
Rehab should target protection of the residuum during their return to functional activities – traditional footwear and toe filler is insufficient to provide adequate skin protection and stability.
“…(I)ntermittent claudication, commonly found in patients with arterial insufficiency, may compromise walking ability and therefore the potential for rehabilitation in this patient population.”

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.”
Wolff et al (2003). “Results of the treatment of infection in both knees after bilateral total knee arthroplasty.” Journal of Bone and Joint Surgery (American) Oct, 85A(10):
Retrospective cohort study: (>20,000 TKRs, 829 treated for infection)
21 patients were treated over a 23 year period for simultaneous infection of TKRs.
Only 1 required 2AKA “… despite undergoing delayed resection arthroplasty (thought to be the treatment of choice with reimplantation in patients with simultaneous bilateral TKR infection) …for control of systemic sepsis.”
“Some patients are poor candidates for reimplantation because of the nature of their medical co-morbidities. In these cases, the definitive treatment is bilateral resection arthroplasty. These patients should be counseled that in general their function will be poor and that most will have pain.” Yeah thanks!
(Acikel et al, 2001, C)
Thermal injury to the lower extremity sometimes necessitates amputation around the knee joint. Knee function is so critical to prosthetic rehabilitation that every attempt should be made to salvage the knee joint. This report presents an unusual case of bilateral lower extremity flame burn requiring amputations. While the distal two-thirds of the legs and both feet were totally necrotic, the thermal damage was limited to skin and subcutaneous tissue sparing muscle and bone in the proximal one-third of the legs and posterior thighs. The below-knee amputation level was salvaged by muscle transposition over the anterior tibia and resurfacing of muscle cuffs with thick split-thickness skin grafts. The post-operative period was uneventful. Amputation stumps tolerated the below-knee prosthesis well and the patient attained independent functional prosthetic ambulation at the post-operative fourth month. It is known from the reconstruction of the plantar foot that skin-grafted muscle tissue tolerates weight bearing and shearing forces well. This principle can also be used for salvage aspects of the below-knee amputation level.

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)
Locking-Cusolito et al (2005). “Prevalence of risk factors predisposing to foot problems in patients on haemodialysis.” Nephrology Nursing Journal Jul-Aug 32(4):
N=232
Nearly 13.4% of subjects had under gone amputations ranging from single toes to bilateral above knee amputations.

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 2nd hand modular components (Marzoug et al, 2003, G Abs).
Ergometry (Vestering et al, 2005, G)
Devlin et al (2004). “Houghton scale of prosthetic use in people with lower-extremity amputations: reliability, validity, and responsiveness to change.” Archives of Physical Medicine and Rehabilitation Oct, 85(8):
Bilateral transtibial amputees made up the majority of subjects in the responsiveness to change test group (Group 2) which looked at changes in scores between the discharge from initial rehabilitation and follow up 3 months later.
The tool is unable to discriminate between unilateral and bilateral transtibial amputees i.e. this tool may not be sensitive enough to highlight the differences in prosthetic use between unilateral and bilateral transtibial amputees.
The authors suggested that Question/section 4 should be omitted for its lack of responsiveness.
“The finding that sample 2 patients, who were assessed early in their rehabilitation and had more people with bilateral amputation (n=46) as compared with sample 1 (n=1), reported fewer issues with stability argues against the face validity of item 4.”
“There was an unexpected preponderance of participants with bilateral transtibial amputation in sample 2, which may affect the generalizability of the results.”
Marzoug et al (2003). “Better practical evaluation for lower limb amputees.” Disability and Rehabilitation. Sep 16, 25(18):
Abstract only, 37 subjects – amputees with doubtful prosthetic potential
Assessed for ability using custom sockets with 2nd hand parts
Median assessment time frame = 4 weeks
Main reasons for prosthetic rejection (58% of cases) were : hip flexion deformity, frailty, bilateral amputations, COAD, stroke, stump pain and contralateral leg problems.
Vestering et al (2005). “Development of an exercise testing protocol for patients with a lower limb amputation: results of a pilot study.” International Journal of Rehabilitation Research. Sep 28(3):
(n=5, no bilateral amputees)
Compared Combined arm-leg ergometry with arm ergometry for a maximal exercise testing protocol. (only 4 completed both tests)
Bilateral amputees were excluded from the study – despite this they were able to draw the conclusion that continuous arm ergometry is a suitable method of testing for bilateral LL amputees.
Tenuous but common sense conclusion.

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

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
Faucher and Schurr (2005). “Ambulation on postoperative day 1 after bilateral transtibial amputations: a case report and literature review.” Journal of Prosthetics and Orthotics. Apr 17(2):
Thigh high rigid casts we’re applied to a 24 y.o. after 2TTA due to a trauma (MVA?+ hypothermic injury). With pylon and feet attached, subject was able to walk on POD1.
Stump wound closure – deep absorbable sutures + external skin staples
Discharged POD 10 walking 100m, doing stairs with handrails
Cast changes at 14 days, 4 and 6 weeks with review of stumps at this time.
“1st Preparatory prostheses” (?) at 6.5 weeks
“This case highlights the utility of accelerated rehabilitation with rigid postoperative dressings in the treatment of a young traumatic bilateral amputee to minimize the time to weightbearing and walking, and the fitting of the preparatory prostheses. This method of treatment should be applied only to patients without peripheral vascular disease or medical conditions that can complicate wound healing. Our patient was in excellent physical condition before his accident.”

11. COMPLICATIONS DVT/PE (Zickler et al, 1999, F)
26% of 2AMPs
Immobile after 2nd amputation
Males
Falls (Kulcarni et al, 1996, G)
27% (4) had falls
Prostheses worn 2:2
Zickler et al (1999). “Deep venous thrombosis and pulmonary embolism in bilateral lower-extremity amputee patients.” Archives of Physical Medicine and Rehabilitation, May, 80(5):
Retrospective review :
27 patients
Bilateral amputations performed within 20 months
Due to DM, artherosclerosis
Follow up information available for 3-64 months
No history of DVT / PE prior to amputation
Received pre and post operative sub cut heparin
All patients at high risk of DVT/PE:
Prolonged immobilization
>40 y.o.
History of surgery
Use of gradient pressure stockings / I/T pressure devices not possible or contraindicated
All patients diagnosed with DVT, PE (7/27, 26%) or both underwent inferior vena cava (IVC) filter placement after the 2nd amputation. The true incidence of DVT amongst 2AMPS was inconclusive – not all patients had duplex scans (11/27).
“No patient ambulated after the second amputation.” – major risk factor for DVT/PE.
There were no significant risk factors highlighted – there was a trend towards gender predicting likelihood of DVT/PE (males more likely). The study was found to be limited by sample size and lack of control group
“It would seem that immobility, in combination with short femoral vein segments in the stumps and decreased return venous flow to the pelvis, are the most important risk factors aside from other known risk factors for venous thrombosis. …prophylactic IVC filters are reasonable in bilateral lower-extremity amputee patients.”
Immobility in bilateral amputees (or for that matter unilateral amputees) of PVD/DM background place them at risk of DVT/PE (1:4 chance).
Kulkarni et al (1996). “Falls in patients with lower limb amputations: prevalence and contributing factors.” Physiotherapy, Feb, 82(2):
Prospective study (164 subjects) - questionnaire which looked at:
Brief clinical history and demographics
Length of time from amputation
Prosthetic use (time) days/week, hours/day.
Falls in the last year
Was the prosthesis worn when the fall occurred
Any injury?
Reason for fall
Effect of fall on confidence, work or leisure
Had they had floor drill training during rehab.
Harold Wood Mobility rating carried out.
Bilateral amputees (n=15)
No. Age (17-64:65+)
2BKA :3
BKAK :1
2AKA :1
New/New + established = 9 (new = amputation in the last 12 months)
Established = 6
There was a significant difference in no. of patients who fell between unilaterals (86, 58%) and bilaterals (4, 27%)
Of the 121 falls, 48% were related to intrinsic patient factors, 12% the prosthesis, 22% the environment and 18% a combination of the above. (no data presented specifically for bilaterals.
50% of bilaterals who fell (2) were wearing their prostheses at the time of the first and subsequent falls.
The authors reported that the bilateral fallers group was too small to reflect any significant trend, “…it begs further investigations into activity levels as ‘walkers’ and the hazards of being a wheelchair user.”
Falls related to prosthesis or environment should be reduced with appropriate education, written instructions on use of the prosthesis, task specific balance and mobility practice and observation of the socket / stump interface.

12. COMPLICATIONS Obesity (Kurdibaylo, 1996, G, Abs) Pain RSD/CRPS
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
Kurdibaylo (1996). “Obesity and metabolic disorders in adults with lower limb amputation.” Journal of Rehabilitation Research and Development, Oct, 33(4):
Abstract only, 94 subjects, various levels (no. of 2AMPS?)
Anthropometric research (skin folds) revealed an increase of body fat mass directly related to level of amputation. The largest amount of fat in the body mass was noted in subjects with bilateral transfemoral amputation or transfemoral plus transtibial amputation (averaged 25.9%)
The frequency of obesity progression in subjects with unilateral transtibial amputation = 37.9%, Transfemoral amputation 48%, bilateral TF or TT/TF 64.2%.
Viejo and Viladomat (1996). “Reflex sympathetic dystrophy in patients with lower-limb amputation: an uncommon cause of pain? [Spanish].” Rehabilitacion, Sep, 30(5),
Abstract only, no details of incidence. One reported case in a bilateral amputee (occurred in the TF stump). Calcitonin may be useful.
Dijkstra et al (2002). “Phantom pain and risk factors: a multivariate analysis.” Journal of Pain and Symptom Management, Dec, 24(6):
Abstract only
Multivariate analysis of 536 subjects.
80% prevalence of phantom pain in lower limb amputees
The most important risk factors for phantom pain were “bilateral amputation” and “lower limb amputation”.
Zuckweiler (2005). “Zuckweiler’s Image Imprinting in the treatment of phantom pain: case reports.” Journal of Prosthetics and Orthotics. Oct 17(4):
Mental Imagery technique used to decrease / eliminate phantom pain and sensation in amputees. One case study looks at the treatment of a 2TTA (1 year apart) >12 months since last amputation. 15 sessions and 20 weeks after the initial session, there was no phantom pain or sensation and a method of eliminating it if it ever returned.
Very interesting case study.

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!”
Warmoth et al (1997). “Case repot forum. Heterotopic ossification associated with traumatic amputation.” Journal of Prosthetics and Orthotics, Winter, 9(1): 33-7.
Case Study of a 50 y.o. Bosnian man who sustained traumatic bilateral transtibial amputations from multiple shrapnel wounds. One year later he was found to have developed heterotopic ossification in both residual limbs.
HO is most commonly seen in SCI, TBI, some “traumatic violent surgical insults” (THRs and acetabular #s) and burns. Characterized by the formation of mature trabecular bone.
HO in trauma – muscle and or bony trauma (usually #s or surgical), repeated microtrauma (horse riders, sites of injection). Incidence levels vary. Factors associated with HO include male gender, previous HO, OA + osteophytes, reduced joint motion, Ankylosing spondylitis, and diffuse idiopathic skeletal hyperostosis.
Incidence of bony overgrowth (differs to HO, spur of bone, no medullary canal) in acquired amputations in paeds is ~12%.
Ortho Surgeons suggested that the HO may have been “periosteal flaps that had ossified.”
Prosthetic limbs were supplied (PTB + pelite liner + sleeve + Springlite® dynamic response feet) and worn hours/day without consequence of HO (pain or wound breakdown) even 6 months after discharge.
The triggering factor for HO is unknown.
Have all patients with proven bony spurs been traumatic / male ?

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 %
HR %
Distance 23-33%
Wheelchair propulsion - more energy efficient for 2AKAs
Wu et al (2001). “Energy expenditure of wheeling and walking during prosthetic rehabilitation in a woman with bilateral transfemoral amputations.” Archives of Physical Medicine and Rehabilitation, Feb, 82(2):
Test conditions:
Wheelchair propulsion
Walking with stubbies and a walker
LL prostheses without knee mechanism with a walker
LL prostheses without knee mechanism and ax.crutches
LL prostheses with (R) polycentric and (L) locked knee and ax. crutches

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
Hoffman et al (1997). “Physiological comparison of walking among bilateral above-knee amputee and able-bodied subjects, and a model to account for the differences in metabolic cost.” Archives of Physical Medicine and Rehabilitation, Apr, 78(4):
Cross-sectional comparison study
“To compare the metabolic cost for prosthetic ambulation among persons with bilateral above-knee amputation with that for able-bodied ambulation, and to test a model that differentiates the metabolic cost of walking into 3 components.”
Subjects 2AKAs with 5 controls matched for gender, height, weight (i.e. transported mass = body mass + mass of prostheses) and age. (1 was a twin).
Variable prosthetic componentry used
1 outstanding (outlier) amputee walker (may have been related to superior prosthetic componentry)
The model to account for the metabolic cost of walking:
Y=ax2 + b
Y = graph curve “Oxygen uptake”
a = metabolic cost of the walking movement
b = basal metabolic rate + other metabolic costs of walking (e.g. balance, posture, increased respiration and heart contraction
x = speed
Aerobic demands 55-83% higher and HR beats higher in 2AKAs than ablebods at any given speed.
Perceived demands 2AKAs > ablebods by 4 points (6-20 scale)
Chosen walking speed 21% slower for 2AKAs (.82 to 1.04 m/sec) but aerobic demand (minute ventilation) remained 49% higher (.98 vs .66 L/min) and heart rate was ~ 40 beats higher despite lower walking speed.
Oxygen uptake: 2AKAs 0.16 ml/kg/m > ablebods for a defined walking distance at any given speed. I.e. Amputee subjects didn’t reduce chosen walking speeds to the extent that metabolic cost per unit time was comparable to that of the ablebod matched group.
Metabolic cost at chosen walking speed for 2AKAs of 0.32 ml/kg/m was 88% higher than ablebods (0.17 ml/kg/m)
There was no significant difference in stride characteristics – voluntary characteristics “…probably result from an interaction between stability and physiological constraints.”
Results are not generalisable to the vascular amputee population
Matching controls “…enhanced the ability to correctly recognize differences between groups.”
Additional metabolic cost for balance and posture – hip and trunk musculature and UL for walking aide use and control.
Additional metabolic cost of the walking motion – impaired exchange of potential and kinetic energy, reduced storage and recovery of elastic energy. It would appear differences in stride characteristics do not account for much change in metabolic cost of walking.

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???
Crouse et al (1990). “Oxygen consumption and cardiac response of short-leg and long-leg prosthetic ambulation in a patient with bilateral above-knee amputation: comparisons with able-bodied men.” Archives of Physical Medicine and Rehabilitation, Apr, 71(5):
Basically a case study cf. 3 able bodied controls.
“…to quantify oxygen consumption and cardiovascular response in a bilateral AK amputee using two different commercially available prosthetic devices and to compare these measured parameters to those obtained from unimpaired control subjects.”
37 y.o. traumatic 2AK (kayaking accident?) 15 months prior to data collection
Body fat 17%
The patient could walk or run (!) without assistance using SL (“stubbies”) but required the use of a stick when using the LL prostheses (Mauch Swing-n-stance hydraulic knee with a modular Flexfoot)
Subject Variable Avg. in 1st stages of Difference b/n conditions (%)
Treadmill Training - 1st w.r.t. 2nd variable
Amputee LL HR LL vs SL +14%
VO %
Ve %
Amputee SL HR SL vs Controls +33%
VO %
Ve %
Controls HR LL vs Controls +52%
VO %
Ve %
The authors note the relatively higher:
O2 uptake – LL > SL > controls
HR response - LL > SL > controls
“The use of currently (1990) available AK prostheses requires significant energy expenditure; this high energy cost limits their application to only the most physically fit amputees. Bilateral amputees with a very low fitness status, such as elderly or vascular amputees, will have a low probability of walking with a prosthesis without extensive physical training.”
The SL prostheses proved to be 24% more efficient than the LL.
The amputee preferred the use of the LL prostheses in social situation because it essentially concealed the impairment… an important psychological consideration.
Type of prostheses had no significant effect on maximal exertion as measured by metabolic and cardiac indices.
The patients measured VO2 max was 56% below age predicted values – this may be as a consequence of the diminished amount of muscle tissue metabolically active during the walking exercise. (compare arm ergo versus treadmill VO2 max measures)

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
Perry et al (2004). “Energy expenditure and gait characteristics of a bilateral amputee walking with C-leg prostheses compared with stubby and conventional articulating prostheses.” Archives of Physical Medicine and Rehabilitation Oct 85(10):
Single Case study.
C-legs enabled patient to “walk farther and faster” than the other 2 types of leg – attributed to longer stride length.
20 MINUTE WALK
Test Stubbies Mauch legs C legs
Distance
covered (m) 772m m m
Speed (m/min)
Speed (% normal)
Oxygen cost range
(% of normal)
Heart Rate
Heart rate was highest using C-leg at all measurement intervals (lowest with stubbies)
Patient was unable to reach steady state of O2 consumption with non-computerised prostheses.
Patient used C-legs ~ 4 days/week (he preferred to use an electrical wheelchair for long distances in the community because it was faster and more efficient. This may explain the increased resting heart rate measure compared with the record 6 yrs earlier).
There was no “conspicuous refinement of motion” using the C-leg so the authors assumed that the improvement in energy expenditure and stride length must relate to “a reduction in muscular effort.”

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
Bilateral Hip Disarticulation
Extreme and rare amputation levels seen in patients with:
Extreme and severe complications of SCI such as multiple recurrences of infected pressure ulcers,
Accident trauma
Congenital anomalies
Malignant diseases of the pelvis, hip and thigh
Large benign hip and pelvic tumours
Osteomyelitis of the pelvis
… when other more conservative treatment methods have been unsuccessful.
Carlson and Wood (1998). “A flexible, air-permeable socket prosthesis for the bilateral hip disarticulation and hemicorporectomy amputees.” Journal of Prosthetics and Orthotics, Fall, 10(4),
Authors were concerned that the following issues were not addressed in many conventional rigid or semi-rigid prostheses for bilateral hip disarticulation and hemicorporectomy patients:
Marked volume fluctuation of the abdomen and trunk
Increased risk of skin shear trauma
Loss of surface area for heat dissipation
Versatile/practical and functional for weight bearing and mobility
Designed a fabric torso socket with 2 suspension straps reflected downward on the outside of a fenestrated rigid frame/shell. The fabric socket aids to accommodate volume fluctuations & reduce shear between the skin and rigid shell – some pistoning in the rigid shell also allows air to be pumped in and out which aids heat and moisture dissipation. The shell is designed to be transferable for use in a wheel chair or in and of itself for upright weight bearing.
Another point to consider – most of these patients have reduced sensation as well (SCI) so careful monitoring is important.
Rogers et al (1993). “Bilateral hip disarticulation management.” Journal of Prosthetics and Orthotics, Jul, 5(3):
Case study which highlights the management of a SCI 49 y.o. male with bilateral hip disartulations secondary to severe decubitus ulcers that did not respond to conservative treatment. Manufacture of prosthetic device to provide sitting support, ambulation opportunities with crutches, cosmesis, intimate fit and increased usage without risk of breakdown is described.
“Physical therapy concerntrated on strengthening exercises, monitoring pressure points and transfer and gait training.”
Trunk strengthening – sit ups, diagonal and normal, upper trunk extension in prone and supine. (NB compensatory movements encouraged to enable function)
Sitting balance – long sitting, bilateral UL support to brief indept sitting
Standing initiated in parallel bars with bilateral UL support. Balance is challenged with arm, head and finally trunk movement.
Mobility progresses from parallel bars to crutches – limited by energy expenditure.
Pt managed to walk up to 50m, some outdoor mobility, and could stand for ADLs (cooking etc).
Dynamic modification of the prosthesis was required.
“Patient education is important in regards to which activities pose the greatest risk to skin integrity and the specific pressure areas to monitor.” Especially in the case of impaired sensation (as in SCI).
Oryshkevich et al (1984). “Sitting orthosis for patient with bilateral hip disarticulation.” Archives of Physical Medicine and Rehabilitation, May, 65(5):
Single Case Study:
A sitting orthosis is manufactured for a patient with bilateral “hip disarticulation” (actually v.v. short AKA but functionally at this level) on a background of (L) CVA (paretic (R) arm and expressive dysphasia) and (R) carotid artery bypass.
The patient required 2 assist to get into the orthosis. It could be strapped to a wheelchair, preventing the patient from slipping forwards and enabling a degree of independence propelling the chair. Sitting endurance eventually increased to > 1 hour and a motorized wheelchair was supplied.

19. Bilateral Hip Disarticulation
Carlson and Wood, 1998 (C)
Marked volume fluctuation
Shear trauma
Heat dissipation
Versatile and functional
Reduced sensation in SCI
Carlson and Wood (1998). “A flexible, air-permeable socket prosthesis for the bilateral hip disarticulation and hemicorporectomy amputees.” Journal of Prosthetics and Orthotics, Fall, 10(4),
Authors were concerned that the following issues were not addressed in many conventional rigid or semi-rigid prostheses for bilateral hip disarticulation and hemicorporectomy patients:
Marked volume fluctuation of the abdomen and trunk
Increased risk of skin shear trauma
Loss of surface area for heat dissipation
Versatile/practical and functional for weight bearing and mobility
Designed a fabric torso socket with 2 suspension straps reflected downward on the outside of a fenestrated rigid frame/shell. The fabric socket aids to accommodate volume fluctuations & reduce shear between the skin and rigid shell – some pistoning in the rigid shell also allows air to be pumped in and out which aids heat and moisture dissipation. The shell is designed to be transferable for use in a wheel chair or in and of itself for upright weight bearing.
Another point to consider – most of these patients have reduced sensation as well (SCI) so careful monitoring is important.

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
Rogers et al (1993). “Bilateral hip disarticulation management.” Journal of Prosthetics and Orthotics, Jul, 5(3):
Case study which highlights the management of a SCI 49 y.o. male with bilateral hip disartulations secondary to severe decubitus ulcers that did not respond to conservative treatment. Manufacture of prosthetic device to provide sitting support, ambulation opportunities with crutches, cosmesis, intimate fit and increased usage without risk of breakdown is described.
“Physical therapy concentrated on strengthening exercises, monitoring pressure points and transfer and gait training.”
Trunk strengthening – sit ups, diagonal and normal, upper trunk extension in prone and supine. (NB compensatory movements encouraged to enable function)
Sitting balance – long sitting, bilateral UL support to brief indept sitting
Standing initiated in parallel bars with bilateral UL support. Balance is challenged with arm, head and finally trunk movement.
Mobility progresses from parallel bars to crutches – limited by energy expenditure.
Pt managed to walk up to 50m, some outdoor mobility, and could stand for ADLs (cooking etc).
Dynamic modification of the prosthesis was required.
“Patient education is important in regards to which activities pose the greatest risk to skin integrity and the specific pressure areas to monitor.” Especially in the case of impaired sensation (as in SCI).

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)
Oryshkevich et al (1984). “Sitting orthosis for patient with bilateral hip disarticulation.” Archives of Physical Medicine and Rehabilitation, May, 65(5):
Single Case Study:
A sitting orthosis is manufactured for a patient with bilateral “hip disarticulation” (actually v.v. short AKA but functionally at this level) on a background of (L) CVA (paretic (R) arm and expressive dysphasia) and (R) carotid artery bypass.
The patient required 2 assist to get into the orthosis. It could be strapped to a wheelchair, preventing the patient from slipping forwards and enabling a degree of independence propelling the chair. Sitting endurance eventually increased to > 1 hour and a motorized wheelchair was supplied.
Rindflesch and Miller (2002). “Technical perspectives. The thoracic suspension orthosis – a seating option for patients with pressure ulcers.” Journal of Spinal Cord Medicine, Winter, 25(4):306-9.
Retrospective case series of 6 patients
Thoracic suspension orthosis (TSO) for patients with bilateral LL amputations or non-healing ulcers +/- surgery +/- chronic sitting pain

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
White et al (2000). “Bilateral kinematic and kinetic data of two prosthetic designs: a case study.” Journal of Prosthetics and Orthotics, 12(4):
Single case study
Comparing two types of trans-tibial prostheses, the authors purporting that “because the patient had bilateral amputations, the changes noted were due to her body’s adaptation to the devices and to the prosthetic component changes.” This is not possible in unilaterals.
The cause of the patient’s amputation was meningococcal septicemia. The patient’s residual limb length and strength were equal.
The prostheses compared were:
“OLD” prosthesis
PTB socket with pelite liner
Supracondylar suspension and sleeve
SACH foot
“NEW” Prosthesis
3-S suspension (silicone suction socket)
Flex Foot
Results – (no significance levels)
Increased:
Velocity (1.22 to 1.4 m/sec)
Cadence ( steps / min)
Stride length ( cm)
Right step length (66-78cm), but no change in left step length (Hhmmmm!)
The new prostheses resulted in an increase in height of 5 cm which may account for some of the increases in gait characteristics.
Ratio of energy generation : absorption
Right Left
Old
New
“…it does indicate a change in the system’s efficiency or the system’s ability to return stored energy.”
Improved ankle motion “Sagittal plane kinematic data revealed total ankle motion changing from 14 degrees to 30 degrees, which is similar to previous findings.” Limitations of link segment model (foot is rigid and no intra foot movement).
Limitations of study: Single case study, latency between data collection times, (manual muscle testing no change but not a good measure of accurate mm strength)

23. Prosthetic solutions St-Jean and Goyette, 1996 (C)
2BKAs fitted with 2 types of skating prostheses
St-Jean and Goyette (1996). “Case report forum. Observations of ice-skating prostheses developed for a 7-year-old transtibial amputee.” Journal of Prosthetics and Orthotics, Winter, 8(1): 21-3.
Case study: 7 y.o. girl with bilateral transtibial amputations as a result of meningococcal infection is fitted with 2 types of skating prostheses. The first allowed “…additional movements at the ankle yet provide(d) good stability.” Ankle dorsiflexion and plantarflexion were permitted – facilitated learning to balance and propel on skates
“As the figure skating skills of the patient improved, a second pair of prostheses was fabricated (1 year later) with more flexible components to increase movement a the ankle.” A Dual-ankle spring, multi-axial rotation system unit was used with a Seattle foot additionally allowing inversion eversion and rotation/torsion at the ankle joint. This allowed for more complex skating tricks.
Interestingly, the child was not a “full-time” walker preferring to alternate between knee walking, prosthetic gait and wheelchair use for the first pair of prostheses but was using “walking legs” all the time at the second fabrication. “Being able to skate motivated (the patient) to use her walking prostheses full-time.”
Basically a technical article explaining the intricacies of aligning limbs for skating (in order to do turns, jumps, parallel skate, maintain contact with ice)
Sometimes my main problem is just getting them to wear and walk in their 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
Adler et al (1987). “Treadmill training program for a bilateral below-knee amputee patient with cardiopulmonary disease.” Archives of Physical Medicine and Rehabilitation, Dec, 68(12):
Single case study:
63 y.o. male with Hx of MI, CCF, CABG x 2, AVR, PVD, DM, moderate COAD and 2BKA. He was a non-smoker
Testing:
Timed walk test
Treadmill test – 12 lead ECG, BP, cardiopulmonary measures were taken every minute, patient was supported in a harness. Energy expenditure was calculated (VO2)
Precise training regimen is not well documented but ranged from:
Walking with “pylons” then canes m.
Arm ergometry ( 0-25watts for 3 minutes up to 3x10 min sets) 3 days / week.
Treadmill (based on HR range and nil ECG abnormalities)
0.5mph for 2-3 min, 3 min rest, harness and rails
0.5mph for 5-10min, 1 min rest, ?
1mph / 1.5% grade for 15 min x 2, 2 min rest, no harness or rails, 3 days / week. Patient preferred to train on equipment but also walked 2 x daily on level ground in hospital.
1.2mph / 2% grade for 20 mins
15-20 mins arm ergo and/or treadmill training 30 mins.
Treadmill testing elicited 90% MaxHR and an ever increasing max. functional capacity of 55%.
2 BKAs have increased energy expenditure mobilizing often on top of compromised cardiac and respiratory systems. Treadmill training can provide a progressive improvement in endurance and cardiac condition (patient changed cardiac classification from 4 to 2) and optimize rehab potential. This patient maintained a home exercise program on discharge (including stairs, gardening household errands). Patient died of cardiac complications 4 years post discharge

25. Mobility Aides 4 footed vs 2 wheeled walkers (Tsai et al, 2003, G)
Speed
(m/sec)
FFW
0.27
TWW
0.5
Tsai et al (2003). “Aided gait of people with lower-limb amputations: comparison of 4-footed and 2-wheeled walkers.” Archives of Physical Medicine and Rehabilitation Apr, 84(4):
Prospective within subjects comparison, 20 Amputees (2 2TTs)
Mean walking speeds for the 2TTs were:
0.27m/s with FFW and 0.5m/s with TWW
Bilateral amputees kept the TWW moving continuously (frame didn’t stop) when mobilizing during testing.
Foot placement (ankle position) was further forward using the FFW than the TWW.
Walker preference: 2TTs chose the TWW over the FFW.
“…the TWW is superior to the FFW in terms of walking velocity and smoothness of gait, without sacrificing users’ safety. Therapists should…take into consideration the other settings in which the aid will be used, as well as the user’s preference.”

26. Sitting balance Kirby and Chari, 1990 (G)
Bilateral amputees
Prostheses on
Prostheses off
Mean difference
Straight forward
Thigh support
Ischial support
94.3
58.5
104.4
99.7
10.1*
41.2^
Anterolateral (45 degrees)
102.3
74.7
110.9
106.2
8.6
31.5^
Kirby and Chari (1990). “Prosthesis and the forward reach of sitting lower-limb amputees.” Archives of Physical Medicine and Rehabilitation, Feb, 71(2):
?Prospective Study
20 unilateral and 7 bilateral (5 2BKAs, 1 2AKAs, 1 BKAK). All subject regularly wore prostheses.
Straight forward and antero-lateral (45 degree) reach was measured with both full thigh support and ischial support only.
With prostheses off, significant difference between forward reach for thigh support and ischial support conditions p <
BUT the authors report that a small sample size for the bilaterals testing means that the results lack power and therefore no conclusions can really be drawn. (Bugger!)
* = p < 0.05, ^ = p <

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)
Dougherty (1999). “Long-term follow-up study of bilateral above-the-knee amputees from the Vietnam War.” Journal of Bone and Joint Surgery (American) Oct, 81A(10):
Review of current function of 2TF amputees from the Vietnam war who had been through rehabilitation at the Valley Forge General Hospital.
30/484 records were 2TF amputees (6%)
88% stumps were primary traumatic amputation
12% stumps were amputation secondary to infection
Arrived at hospital 4.5 weeks after injury
Average initial prosthetic fitting 8.3 weeks
57% (17) patients were fitted with permanent prostheses at an average of 6.4 months.
10% (3) had died since D/C from hospital
23/27 patients completed surveys (average age 47.8 yrs, average 27.5 yrs after injury) 4 couldn’t be contacted.
16/23 (70%) were or had been employed
21/23 (91%) were married
20/23 (87%) had children
16/23 (70%) fitted at the hospital with prostheses, 6/23 (26%) fitted post discharge – 1/23 was never fitted, had very proximal amputations. 5/23 (22%) still wore prostheses at an average of 7.7 hours per day. 4 others (17%) used legs when going outside the home. 10 respondents (43%) had used legs to walk for an average of 12.9 years. Prosthetic replacement average 3.8 times.
18/23 (78%) used wheelchair as primary means of mobility.
SF-36 (QoL quest) – compared with normals, physical functioning significantly lower but no difference on other measures (pain, general health, vitality, social functioning, emotion and mental health).
1/23 patient reported receiving treatment for post traumatic stress disorder. 4/23 others had used services such as AA’s and marriage counseling.
“Walking with the use of prostheses may have become more difficult as the patients gained weight or sustained injuries of the shoulder.”
“ The fact that graduate medical education programs in orthopaedic surgery have de-emphasized amputee care further increases the gap in learning (referring to the reduced likelihood of matching quality of rehab / amputee care now due to lack of practice in military hospitals).”
Limitations of the study noted were:
Most of the patients had been officers of some description – their character and personality may have lent towards more positive rehab outcomes.
Comradeship of the armed forces doesn’t transfer results into the civilian population
“In contrast to the portrayal in the popular media, the present study provides evidence that those who have sustained a bilateral above-the-knee amputation on the battlefield are not automatically condemned to live with severe physical and emotional difficulties. The patients in this long-term follow-up study have led relatively normal, productive lives within the context of their physical limitations.”
* not all records were complete

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
Nissen and Newman (1992). “Factors influencing reintegration to normal living after amputation.” Archives of Physical Medicine and Rehabilitation, Jun, 73(6):
Questionnaire/survey of 42 amputees
26% were bilateral amputees (7% 2BKA, 9.5% BKAK, 9.5% 2AKA)
Though not strictly tested, the authors report that “…the addition of bilateral amputation did not alter the overall RNL (reintegration to normal living) score.”
Quite possibly these individuals may have had severely limited “normal living” prior to amputations. The study group comprised of “elderly” individuals (68 +/- 1.5 years, range 42-95).
Only illnesses in addition to amputation made an impact on RNL – most had multiple medical problems. DM was not perceived as altering RNL.

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”
Thornhill et al (1986). “Bilateral below-knee amputations: experience with 80 patients.” Archives of Physical Medicine and Rehabilitation, Mar, 67(3):
Retrospective assessment of 80 subjects, all 2TTs
Similar population as Brodzka et al (1990) – received restorative care at Harlem Hospital Center, from March Dec 1982.
Discussion:
51% of total group were male, females predominated in the atherosclerotic (AS) sub-group (54%)
Degenerative arterial disease was the main cause (86%)
Mean age at 2nd amputation was 58 years, 68 in AS group, 65 in the successful prosthetic users group
No contralateral limb survived 6 years or longer.
57% of AS patients died over the course of the study (avg. 44 months for those deceased, survival time was avg. 64 months at end of study)
“Considering limited life expectancy, (rehabilitation) efforts should be expedited with early reintegration into their places in society, avoiding unnecessarily lengthy periods away from their homes.”
95% prevalence of hypertension or diabetes (75% combined HT & DM)
<5% required revision
71% prosthetic usage amongst the AS group (any amount of walking 3 x / week). Reasons for non-usage included mental health issues, reduced CV reserve, stroke and contractures. (“65% to 75% successful prostheses use might be a reasonable expectation among an unselected group of bilateral BK amputees. The most common reason for prosthesis failure in both our groups was mental impairment.”)
All previously employed AS group amputees returned to work.
Non-AS outcomes
Younger
Predominantly male
Psychosocial pathology was the major determinant of the amputation, prosthetic usage and long term disability – discharge from psychiatric hospitals and lack of adequate community support systems was probably contributory.
“(T)he non-AS patients, for the most part at the bottom of the socioeconomic ladder, represent extreme examples of the quiet but devastating physical loss and resultant disability that can develop in patients with severe psychiatric disorders aggravated by marked socioeconomic disadvantage” An effective support system may have improved outcomes.

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
Brodzka et al (1990). “Long-term function of persons with atherosclerotic bilateral below-knee amputation living in the inner city.” Archives of Physical Medicine and Rehabilitation, Oct, 71(11):
Descriptive study – Follow up assessment
Long term function of 24 elderly persons with atherosclerotic 2BKA living in the inner city for at least 6 months after the second amputation, was determined.
African American subjects in Harlem (Thousands of stats and percentages)
Demographics:
Equal male:female, Age ranges 54-83: 65-95
2BKA Chronology
70% (R) BKA first
Time 1st to 2nd amputation 0-76 months (mean 28 months)
Time 2nd amputation to interview 6 months to 19 years (mean 4.9 years)
Associated medical conditions
Hypertension (75%), DM (62.6%), Cardiac disease (33.3%) Orthopaedic conditions (29.2), CVA (20.8%), Dementia (16.7%)…
Housing
83.3% Rented accommodation, 1 subject owned home, 3 in NH
9 subjects lived alone
Bathrooms were wheelchair inaccessible in 11 (45.8%) instances, the toilet in 10 (41.7%), the front access in 11 buildings (no buildings had ramps)
18 (75%) lived above the ground floor
ADLs
All with prostheses donned them independently (12)
All had special adaptations for bathing
15 dressed independently
18 households received daily assistance from services or family
Social activities
Only 8 (33.3%) were involved with social contacts outside the home.
20 (83.3%) received visitors at home.
All were retired before the 1st amputation
Mobility levels
20/24 received prostheses (4 had severe dementia or multiple medical problems)
12(60%) still wore prostheses between 3-12 hours / day
10 still walked at home, 8 daily, 7 independently
3 went out daily
6 could negotiate a flight of stairs
Assistive devices – 7 used walkers, 2 used sticks, 9 used wheelchairs for long distances, 1 managed without anything
Public transport: 5 used bus or cab
Maintenance of ambulatory skills
Ambulators maintained skills from discharge to interview (mean 4.87 years post 2nd amputation) except 1 who had lost her companion. Majority were women
Nonambulators lost walking capacity an average of 3.47 years after 2nd amputation. The majority were men
All nonambulators were dependant on others for household chores
Preservation/loss of prosthetic ambulatory skills
Nonambulatory subjects were older at amputation
Time from 1st -2nd amputation: no difference between ambulators and nonambulators, shorter time interval for those who were no longer able to walk (23 month mean, 33 months for ambulatory subjects)
Medical conditions: 7 persons no longer able to walk had 3-5 medical conditions, cardiac disease was higher in this group. Loss of vision lead to loss of ambulatory capacity.
Stump problems: 4 nonambulators had problems (severe oedema, intractable pain, fractures in 2)
Housing: Ambulatory preservation or loss had similar housing except 4 (1 had a bathroom in disrepair, 3 in NH. One in the nursing home had legs but had become wheelchair bound after admission to the NH.)
Achievements: Those no longer able to ambulate had seldom reached the same level of function as those still walking. One 68 y.o. subject walked independently managing “20 blocks”; most managed 1-3 blocks.
Subject comments
8/10 ambulatory subjects expressed satisfaction
6/10 who had lost ambulatory skills felt, given other medical problems, they were doing satisfactorily
All subjects were pleased with rehab and care they had received
4 wheelchair bound subjects complained about their housing situation – small space, dilapidated bathroom, living with relatives, moved due to increased rent.
3 stated existing support was insufficient (non-eligible subjects)
2 had financial difficulties
Mortality
8 (33.3%) died before end of study, mean age 81.3.
4 were active ambulators for an average of 9 years
2 had lost previous skills
2 never had prostheses
Mean survival time after 2nd amputation was 9.2 years for those deceased, 4.7 years for those still alive at the end of the study.
DISCUSSION
Women were older than men – a reflection of the shorter lifespan of African American males
Social security was a source of income in most (79.2%) and most were also Medicaid recipients (75%) – reflects the low socioeconomic of the population studied. Housing was adequate in all but a few exceptions.
Difficulties for 11 (45.8%) subjects were wheelchair inaccessible buildings and bathrooms.
Medical conditions were consistent with those of other authors, 19 patients had a combination of 3-5 disorders
Subjects were older at second amputation than other studies
Mean between amputations was 28 months (others = 23 months)
20/24 were issued with prostheses, 12/20 still wore them, 10/12 worn daily, 10/20 maintained ambulatory skills, 6 community walkers (4 no assist), 7 walked indoors unassisted.
10 subjects lost ambulation skills (mean 3.47years), 3 within 3 months, 7 from 1-10 years. Thus 17/20 remained ambulatory for a significant period.
Those who lost ambulatory skills were older and had a shorter interval between 1st and 2nd amputation. More likely the number and severity of comorbidities had the most detrimental effect on ambulation – cardiac disease, dementia, parkinsons disease, multiple myeloma, severe chronic stump problems (in line with other studies that relate deteriorating prosthetic mobility to reducing physical and mental health.)
Regarding ADL only 1 95 y.o. wheelchair bound and demented subject was fully dependent. Bathing was the most difficult activity. 20/21 subjects living at home required housekeeping support. Only 1 subject did his own shopping. Access to personal and household services was generally the major determinant of subjects’ ability to avoid transfer to a nursing home and to remain safely in their own homes.
Ambulatory patients were more outgoing than wheelchair bound persons – access may have been a contributing factor. One outstanding subject had superior achievements.
Mobility appeared to be the key factor determining functional capabilities – most authors agree that functional prosthetic ambulation is a good indicator of successful rehabilitation outcome in both general and 2BKA populations. (There was a notable exception of a wheelchair bound individual who still managed overseas travel.

32. SUMMARY Bilateral amputees provide a unique opportunity for:
Research
Innovation
Mobility is the key to functional (?successful) outcome.
Complications of decreased mobility
Bilateral amputees provide a unique opportunity for prosthetic research – subjects are not able to compensate with the intact limb.
“because the patient had bilateral amputations, the changes noted were due to her body’s adaptation to the devices and to the prosthetic component changes.” (White et al, 2000)