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Major Lower Limb Amputation

Major Lower Limb Amputation

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Published by: Alexandre França on Jul 05, 2011
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Major lower limb amputation e what, why and how to achieve the best results
Vicky Robinson Kate Sansam Lynn Hirst Vera Neumann

This article is an introduction to rehabilitation after major lower limb amputation e what to expect once your patient leaves your care and what you can do to assist the rehabilitation process. Each section corresponds to the World Health Organization’s (WHO) international classification of functioning, disability and health (ICF); see Figure 1. This model describes the impact of a health condition on an individual by classifying not only changes in body structure and function, but also considering the effects of external environmental and personal factors, bringing them all together to emphasize health and functioning rather than disability. Implementation of this model by the multidisciplinary rehabilitation team leads to more effective outcomes for the patient by identifying pathological processes, functional limitations, impairments and disability.1 The multidisciplinary team is at the core of managing these patients with long-term, often complex, conditions and comorbidities; one healthcare professional cannot possess all the knowledge needed for effective rehabilitation and several specialists will have input at various time points. The most effective tool used by this team is individualized goal setting with each patient e there is such a diversity of age, ability and functional loss that this is one of the few tools that enable effective planning and measurement of achievement for adults and children at all levels. The patient’s long-term goals should be discussed before surgery (where possible), as with careful consideration the technique used, or level selected, may be different from the immediately obvious choice. There is an emphasis throughout this article on the pre-amputation consultation e a meeting with the rehabilitation team to enable realistic goal setting. For an example of this, consider an elderly dysvascular amputee with several co-morbidities, who is unlikely to use a prosthesis functionally. If vascularity allows, it may be preferable to carry out a knee disarticulation rather than trans-femoral amputation e a quicker operation associated with less peri-operative blood loss yielding a residual limb with preserved muscle balance, reduced risk of contractures and pressure ulcers and a long lever arm useful in assisting sitting balance and transfers. This type of decision requires careful discussion, as there are other issues, such as the cosmetic result, that will be important for some patients. Another common scenario is the diabetic patient with a foot ulcer; a partial foot or Symes amputation are often the first choice, however these are difficult to fit with a prosthesis due to the small space available for components. Preference may be given to a trans-tibial amputation in many cases, as a good functional outcome is easier to achieve. In contrast a child will benefit from a Symes amputation, as the growth plates are retained, reducing the risks of bony growth spurs. The amputated side will continue to grow, but often at a slower rate than the sound side, resulting in a highly functional end-bearing residual limb with adequate space for more advanced prosthetic components. The main types of amputation, as recorded by the National Amputee Statistical Database (NASDAB)2, are listed in Table 1. There are outlines of the prosthetic choices for these levels within the activity section.

This article is intended as an overview of rehabilitation following major lower limb amputation; which surgical techniques can improve outcomes, why they should be considered and how the rehabilitation team works once patients have left the care of the surgical team. It is aimed primarily at orthopaedic and trauma surgeons, but also contains references to dysvascular patients, as this is the primary cause of lower limb amputation in the UK. The different aspects of rehabilitation after an amputation will be presented using the World Health Organization’s international classification of functioning, disability and health. The domain of health condition includes the aetiology of amputation and a brief history of prosthetic provision. The impairment section covers surgical techniques and how they can help improve outcomes for patients along with pre and post-operative pain management. An activity section contains an introduction to physiotherapy and early walking aids, with an overview of prosthetic assessment and the common component types. The participation section goes into appropriate goal setting and realistic outcomes that patients can expect. The final section on social and environmental factors briefly covers psychology and motivation. A vignette of key learning points concludes the article.

Keywords amputation; lower extremity; MeSH terms; prostheses;

Vicky Robinson BSc Hons Prosthetics and Orthotics PG Cert Health Research Senior Prosthetist, Best Practice Lead at the Prosthetics Department, Seacroft Hospital, York Road, Leeds, UK. Kate Sansam MB BChir MA MRCP Locum Consultant in Rehabilitation Medicine and MD Student at the Academic Department of Rehabilitation Medicine, University of Leeds, Level D, Martin Wing, Leeds General Infirmary, Great George Street, Leeds LS1 3EX, UK. Lynn Hirst BSc Hons Physiotherapy PG Cert Amputee Rehabilitation Senior Prosthetics Physiotherapist at the Prosthetics Department, Seacroft Hospital, York Road, Leeds, UK. Vera Neumann BA MBBS MD FRCP Consultant and Honorary Senior Lecturer at the Rehabilitation Medicine, Academic Department of Rehabilitation Medicine, University of Leeds, Level D, Martin Wing, Leeds General Infirmary, Great George Street, Leeds LS1 3EX, UK.



Ó 2010 Elsevier Ltd. All rights reserved.

free at the point of delivery. All rights reserved.2 The Artificial Limb Service in England was created in 1915 to treat the large number of soldiers who had lost a limb during the First World War. such as stroke. Health condition Lower limb amputation is a common clinical problem. Some may have a strong wish to minimize risk of further surgery. with around 7000 leg amputations occurring in the UK per year. Of these.4 In common with other industrialized countries the majority of new amputees are now elderly patients with dysvascular disease. such as. rather than the young war injured seen at the inception of the service. to those with limb deficiency from all causes. amputation in the middle third of a long bone is appropriate. If mobility is expected to be very limited.2 As well as the provision and maintenance of prostheses the services also provide advice and treatment in the management of pain. If the residual limb is long. if the residual limb is left too long. As a result. when the prosthesis is worn in sitting the prosthetic knee will protrude forwards. Over the years the range of components available has increased significantly and around 80% of prosthetic service users in England and Wales now have modular limbs. the UK amputee rehabilitation service in the UK has changed over the decades. . In order to estimate potential mobility. There are now 42 NHS Prosthetic and Amputee Rehabilitation Centres in the UK providing a service. A similar consultation is available to parents of children with congenital limb deficiency. the likely functional outcome and the rehabilitation process that they would have to participate in to achieve those outcomes can be discussed. sensation and/or perception and/or cognitive function. As modular limbs are constructed from a choice of individual components. ischaemic heart disease or chronic obstructive pulmonary disease  interfere with power or movement control. allowing at least 12 cm clearance above the knee joint line in trans-femoral amputees and 10 cm below the knee in trans-tibial amputees. the patient may experience difficulty reaching household appliances or other objects because they cannot sit close enough to the working surface. this allows for quicker provision of completed individualized prostheses. Successful fitting of a prosthetic limb demands adequate residual limb length to transmit load (body weight) and suspend the prosthesis. in adults. Patient preference is an important consideration. The average age of patients attending these services is 65 years and 72% have their lower limb amputation due to vascular pathologies with trauma now only accounting for 7% of patients. This is a particular concern following trans-femoral amputation. residual limb skin problems and prevention of further amputations. However. many other factors need to be taken into consideration. either before or after birth depending on when the condition is detected. a knee disarticulation followed by wheelchair use may be the best method of allowing someone to maintain independence in mobility and personal care. the energy demands of each amputation level (see Figure 7 below) must be considered alongside the presence and severity of co-morbidities. steel and block leather construction being largely replaced by lighter weight modular limbs that are still sufficiently strong to withstand the forces involved in walking.3 Initially only providing free prosthetic limbs to war pensioners. However. Potential complications such as phantom pain. Parkinsonism or diabetes associated with sensory and/or visual impairment  are associated with impaired musculoskeletal function such as rheumatoid arthritis. osteoarthritis or low back pain. 65% will be referred to a prosthetic and amputee rehabilitation service for consideration of a prosthesis. Early referral to the specialist rehabilitation service is recommended to provide the best possible information and advice for parents. knowing there is a risk that this may not heal eg due to dysvascularity or excess tissue damage and a more proximal amputation may then be Lower limb nomenclature 09 10 11 12 13 14 15 16 Table 1 Hemi-pelvectomy Hip disarticulation Trans-femoral Knee disarticulation Trans-tibial Ankle disarticulation (Symes) Partial foot Digits ORTHOPAEDICS AND TRAUMA 24:4 277 Ó 2010 Elsevier Ltd.AMPUTATIONS AND PROSTHETICS Figure 1 ICF components and interactions. Impairment Before the operation Selection of the appropriate amputation level depends in part on the extent of the underlying pathology. the field of prosthetics developed rapidly during the twentieth century with previously heavy wooden. whilst others may opt for a trans-tibial amputation. aluminium and titanium. For patients considering an amputation. there will be insufficient space to allow prosthetic joint components to be inserted and act at the same level as the equivalent natural joint in the intact limb. Due to the increased demand from two World Wars and the development of new materials such as plastics. a range of which can be kept in stock. a preamputation consultation can be arranged at the prosthetic centre to aid understanding of the implications of undergoing an amputation. with more rapid replacement of worn parts when required. As a guide. particularly problems that:  impede stamina.

. need to know that healing can be difficult to predict. good peri. Surgical technique The most successful surgical techniques when fashioning the residual limb are those that:  Minimize the risk of developing pressure ulcers. improving the person’s actual involvement in work. this will of course vary between patients and depend on other factors such as ORTHOPAEDICS AND TRAUMA 24:4 278 Ó 2010 Elsevier Ltd. NICE is shortly to publish guidelines for the management of neuropathic pain. leisure activities.5  Bury nerve ends such that when a neuroma forms as the nerve attempts to regenerate. with complexity added for more active patients at the expense of adding weight and often requiring more maintenance. such as walking.and post-operative analgesia is vital. Disarticulation through the joint proximal to the underlying pathology avoids this problem.AMPUTATIONS AND PROSTHETICS needed. In particular. Dysvascular patients. sufficient muscle should be left to act as a protective cushion against pressure ulcers over cut ends of bone. surgical excision of the neuroma is seldom necessary. Nevertheless. Patients need to be aware that there is a risk of pain in the residual limb or perceived in a phantom limb. etc. so that he/she can learn more about what to expect following surgery. Where pain is triggered by contact with. generally due to adductor laxity and abductor tightness and may require additional semi-rigid suspension. the nerve ending may be “burnt” off with a cryoprobe8 or guided phenol injection. Normal human movement is complex and a prosthesis cannot replicate every function. Advice should be sought from the rehabilitation physician regarding this. only 4e6% of patients have pain sufficient to interfere with sleep or daytime activities 1 year following amputation with appropriate treatment (see pain management). Locally applied lignocaine patches or capsaicin may be helpful. a bulbous residual limb can make this impossible. Simplicity is the guiding principle to prosthetic design. but this risks leaving the fully grown child with a proportionally very short residual limb. contact can be reduced or avoided by adjustment of socket fit. difficult for loading and suspending a prosthesis. reducing his/her risk of joint contractures. the parents and their children need to be as fully informed as possible about the pros and cons of amputation. a wound closed under tension with poor quality skin is inevitably more vulnerable. this unfortunate minority may find that their pain rules their lives. and that post-operative diabetic control. influence healing outcome. avoid bony spurs and muscle imbalance. Their recommendation. In our experience. Bony overgrowth can be limited by stapling or ablation of the epiphyseal growth plate. In all cases where surgery is elective. but losing the function of this joint may have a major impact on function with a prosthetic limb. many parents (and children) opt for the inconvenience and discomfort of recurrent surgery for bony overgrowth to have a chance of superior function throughout life as an amputee.  Leave muscles in the residual limb secured to the periosteum so that they can still act effectively to control residual limb movement and hence move the prosthesis. though evidence for these is limited. diet and smoking. their mass and inertia forces. triggering neuropathic pain. thus less vulnerable to shear damage during prosthetic limb use. they need to be aware that following amputation through the shaft of a long bone.  Shape muscles and the overall residual limb such that the patient can get his/her prosthesis on and off. necessitating revision surgery. based on evidence review will indicate that the most effective and cost-effective pharmacological treatments are pregabalin and/or amitriptyline. and difficulties in performing these are referred to as activity limitations. the potential amputee should be offered the opportunity to meet an existing amputee. particularly those who are also diabetic. etc.  For trans-femoral amputations. or pressure on. etc. Good management by amputee specialists. hygiene and cosmetic acceptability of materials. pressure ulcers. This involves careful planning of skin flap length and design. a so-called “rigid pelvic band”. the bone will continue to grow more than the surrounding soft-tissues and may then protrude through the skin. Pain management Peri-operative epidural analgesia for elective amputation was thought to reduce the likelihood of developing troublesome neuropathic pain in the residual and/or phantom limb. distraction techniques such as hypnotherapy. However. Activity The ICF classification of activity is the execution of a task or action by an individual.  Ensure that resulting scars are mobile and located away from maximum pressure or friction. Successful prosthetic rehabilitation is more likely if the time waiting for the prosthesis is minimized and the condition of the residual limb is optimized. including physiotherapy.6 but subsequent well-conducted studies have been unable to reproduce this finding. All rights reserved. occupational therapy. When considering amputation in a child. There are many factors to consider in a prosthesis design such as durability. The rehabilitation process should also take into consideration factors other than physical ability such as environmental barriers and motivation. Given this choice. to overcome this difficulty. In other patients. nursing and rehabilitation medicine physicians at an early stage post-op is recommended for the best results. to enable increased participation. A time line of events is shown in Table 2 as a guide to referral times. not only for patient comfort but also to ensure that the patient can participate in early mobilization. thromboembolic disease. etc may also be effective. Amputee rehabilitation aims to address specific limitations. preferably someone with a similar level of function to that anticipated. In order to reduce an amputee’s activity limitations the ideal prosthesis should function exactly like the body part it is replacing. particularly in young children or adolescents who have just completed chemotherapy for a bone tumour.7 Nevertheless. This growth is often surprisingly rapid. a neuroma. the femur should be brought into its normal anatomical alignment before suturing the remaining adductor and abductor musculature to its periosteum or attaching to bone. Often. otherwise the patient may find it very difficult to maintain correct alignment of the prosthesis during use. this is not subjected to contact/pressure during prosthetic limb use. Non-pharmacological treatments such as TENS. but evidence for these is lacking.

prosthetist wound healing and cardiovascular health. complications with prosthetic fitting and poor prosthetic gait patterns. positioning. Environmental home visits will be necessary to ensure the patient can access all areas of their home in their wheelchair. These often occur at the hips and knee(s) of a lower limb amputee. Early post-op rehabilitation OT/PT A specialist multidisciplinary team (MDT) achieves the best rehabilitation outcomes for lower limb amputee patients. PT. washing or toileting. is an inflatable structure with a simple rocker foot. therefore movement should be limited to safe transfers until prosthetic provision. It can be used for trans-femoral and trans-tibial amputees commencing from seven days post-operatively. muscle stretching and strengthening and adequate pain control to prevent flexor withdrawal patterns.AMPUTATIONS AND PROSTHETICS 1e2 years Review. Details of each stage are covered below. The risk of injury. All rights reserved. may be decreased with provision of residual limb protectors. The Occupational Therapist (OT) and Physiotherapist (PT) play a key role in coordinating early rehabilitation and successful discharge home. surgeon 1e7 days PT Rehab consultant PT/OT. a Zimmer frame or rollator. This can result in injury to the healing residual limb. following agreement between the surgeon and the physiotherapist. . Pre-prosthetic mobilization should be in a wheelchair unless there are specified reasons to teach a patient to use crutches. A reduction in. exercises and compression therapy. Occupational therapists will assess for appropriate wheelchair provision and other equipment necessary to assist independence and build confidence. shown in Figure 2.10 The Pneumatic Post-Amputation Mobility Aid (Ppam aid). When patients are unable to gain access to a certain area of their home Intermediate Care Team (ICT) provision. The Ppam aid should be used in accordance of the Ppam aid guidelines 10 weeks plus Gait training Assessment/cast for first prosthetist Pre-prosthetic gait training Early post-op rehab Prosthetic fitting 8e10 weeks 7 days to 6/8 weeks 6e8 weeks Timeline of prosthetic rehabilitation Surgery PT/OT. The physiotherapist can assist in reducing oedema of the residual limb via education. Loss of range of movement can occur at any joint when an amputee is relatively immobile. Contractures greater than 25 at the knee or 30 at the hip may preclude prosthetic fitting altogether because of the associated mechanical disadvantages for the patient. help to reduce oedema and prepare the residual limb for prosthetic limb wearing. nurse. if a fall occurs. centre of gravity and the presence of phantom limb sensation. prosthetist Prosthetist PT Table 2 ORTHOPAEDICS AND TRAUMA 24:4 279 Ó 2010 Elsevier Ltd. may be necessary on discharge to assist with meal provision. adjustment and recasting Rehab consultant. nurse. Lower limb amputee patients are at high risk of falls in the immediate post-operative period due to the significant change of balance.9 The risk of falls may be reduced through education and exercise. but contractures are the chronic loss of joint motion due to structural changes in soft tissue. Early prevention is the best option via residual limb positioning. They provide a psychological boost for patients. or lack of movement at these joints can cause delayed wound healing. These therapies can also assist in pain control and reducing phantom limb sensations. Pre-prosthetic gait training Early walking aids (EWAs) are used to initiate gait re-education soon after surgery. or their international equivalent. Occupational therapist: the amputee patient should be encouraged to regain their independence in activities of daily living (ADLs) as early as possible.

Prosthetic assessment Referral for prosthetic assessment is generally made by the physiotherapy or occupational therapy team who have been involved in the patient’s immediate post-operative care. a particularly useful tool when patients are on the prescription borderline between a free and a locked knee (see prosthetics assessment section). Through regular assessment the physiotherapist will identify when the patient has attained realistic goals and optimum function with a prosthesis and facilitate a maintenance programme. However.AMPUTATIONS AND PROSTHETICS Figure 2 Ppam aid. All rights reserved. social network and psychological presentation influence the expected level of functional independence. The physiotherapist should teach efficient control of the prosthesis through postural control. and safely. weight transference and use of proprioception. These functional tasks will be related to the individual goals (see below for further details and examples of goal setting). and is made up of a rigid socket. Gait training The aim of prosthetic gait training in rehabilitation is to achieve maximum independence. pain management and for Figure 3 Amputee mobility aid. With specific muscle strengthening and stretching exercises to prevent and correct gait deviations. Figure 3. . is the second generation to the Ppam aid and allows more natural gait for trans-tibial amputees through flexion and extension of the knee and mobility with a prosthetic foot.2 The majority of NHS amputee rehabilitation services in the UK are partly subcontracted to private companies who employ prosthetists and prosthetic technicians and run workshops to manufacture prosthetic limbs.11 The Amputee Mobility Aid (AMA). This allows for assessment using basic mechanical knee componentry. expectations and medical limitations. The latter most frequently arise as a consequence of a mismatch between socket and residual limb volume. with minimum extra energy expenditure. Nationally 70% of referrals to prosthetics centres are made within 1 month of the amputation being carried out. The level of amputation. the rehabilitation physician will monitor for problems with concurrent medical conditions. Patients will be individually assessed for the provision of walking aids. soft tissue infections or dermatitis triggered by irritation from or allergy to socket materials are also common. developed by The Scottish Physiotherapy Amputee Research Group. a knee unit that can be locked or free and a prosthetic foot with an adjustable pylon to set the correct height. The Femurett. Rehabilitation with the prosthesis should be functional and gradually progress in complexity. An individual rehabilitation programme takes into account patients’ pre-amputation lifestyle. which progress towards full weight bearing through the prosthesis and aids to functional tasks. other medical conditions. as the latter shrinks during healing and prosthetic use. Figure 4 is used for trans-femoral amputees. residual limb problems. The manufacturing facilities and ORTHOPAEDICS AND TRAUMA 24:4 280 Ó 2010 Elsevier Ltd. Gait training will continue after the provision of a prosthetic limb. Throughout this initial rehabilitation time (usually the first year).

and ischial containment. often in conjunction with local amputee physiotherapy services. co-morbidities and motivation to formulate the initial prescription. In contrast. progress made during preprosthetic gait training. Prosthetic components The subject of prosthetic components is a large one covering materials. Since many patients have compromised cardiovascular and respiratory function. as there are many factors to take into consideration12 and no objective tools that can reliably predict mobility levels. the energy costs of ambulating with a prosthesis must be considered. absorb some of the shear forces and provide suspension through a distal connection. Together they will work with the patient and any family members who have accompanied them to discuss provision of a prosthetic limb and set appropriate goals and timeframes. quality of the socket fit. with the greater trochanter and femoral shaft used to provide stability. by their nature. A soft foam insert in conjunction with a rigid outer shell provides more padding and allows adjustment.AMPUTATIONS AND PROSTHETICS into the prosthesis for a frail patient may make the prosthesis excessively heavy. for example early after surgery or when taking medications such as diuretics. stabilization and allowance of muscle function. this is usually achieved by wearing a sock. designed to withstand higher activity levels. Here we will cover the basics of residual limb interface. biomechanics and fluid dynamics through to indications and contraindications for each patient. as described above. Ankle and knee disarticulation amputations have the advantage that weight can be taken through the distal end of the remaining bone for near normal force transmission.13.14 Trans-femoral residual limbs do not have the same problems as trans-tibial. they may benefit from prosthetic components that are more complex and heavy duty. Many centres run limited satellite clinics. where the ischium and ramus are contained and the socket is narrower medio-laterally to maintain that contact and stabilize the femur. quadrilateral. All rights reserved. These types of sockets are often suspended by gripping onto the supracondylar areas of the femur. which includes a rehabilitation medicine consultant. When patients are expected to be very active from an early stage. . specialist nurse. the patient will not be able to walk. They offer many advantages to patients but are contraindicated for patients in whom the residual limb shows significant fluctuations in volume. incorporation of such components Excess energy demands in comparison to normal walking1 Level Trans-tibial Bilateral trans-tibial Trans-femoral Hip disarticulation Table 3 Effort (kcal/m) þ41% þ60% þ89% þ200% Reduction in gait speed 36% Not available 43% Not available ORTHOPAEDICS AND TRAUMA 24:4 281 Ó 2010 Elsevier Ltd. This is because elastomers deform easily but generally maintain a constant volume. main centres are regional due to the relative low density of amputations in the population and the complex machinery required for fabrication. Suspension can be through belts. and the consequent reduction in walking speed. At presentation the MDT will consider the patient’s pre-amputation mobility. Impermeable elastomer layers are best avoided over an unhealed wound. occupational therapist and rehabilitation engineer on the team. Advances in prosthetics have produced an alternative interface. It should be noted that these are estimates. though does add to the bulk of the prosthesis. Table 3 gives a guide to the additional energy requirements above that of normal subjects. Generally the first limb will be the simplest design suitable for the patient’s expected activity level in order to keep the limb as light as possible. elastomer liners. These vary according to the level of amputation and depend on the weight of the prosthesis. There are two main socket shapes in use. Once referred to the amputee rehabilitation centre. Sockets and interfaces: the socket and its interface with the residual limb are crucial to successful prosthetic fitting e the socket must transmit weight bearing forces through the limb and if this is not comfortable. have areas of bony prominence which need protection. Suitability for a prosthesis is assessed by the rehabilitation team. There may also be a clinical psychologist. specialist physiotherapist and prosthetist. Table 4 gives a guideline to the types of components used for each level of amputation and predicted ability. figures inevitably depend on individual characteristics such as height. often 4 weeks. Sockets are rigid. Weight is borne through the ischium. weight and exact amputation level. though may have some flexible areas proximally for comfort. Predicting outcome is a difficult process. plus the Figure 4 Femurett. there is usually good soft tissue coverage and the main concerns are effective transmissions of forces. counsellor. which is narrower anterioreposterior to keep the ischium on a seating area. Trans-tibial amputations. which provides padding and moisture wicking. accuracy of prosthetic alignment and the functional characteristics of the components. patients are offered an appointment within a set time. or when on treatments such as dialysis. knees and feet. though there is observational evidence that it is safe and indeed there may be an advantage to proceed with prosthetic fitting even in those who have unhealed residual limb wounds. These liners are available in various materials including silicone and polyurethane gels of different thicknesses and densities. which are worn next to the skin. a close contact suction system or elastomer liners.

though do add weight. The most basic type of non-articulated foot is the SACH (solid ankle cushion heel) in which movement is only provided by the softness of the heel material. All rights reserved. multiaxis and dynamic. Individual torque absorber and shock absorber units are also available to provide similar characteristics to any feet. thus simulating the anatomical axis of motion of the human knee more closely. They are particularly useful for long residual limbs or knee disarticulations. nonarticulated. they will perceive it as stiff and unaccommodating. Knees The action of the anatomical knee is difficult to replicate and it is more difficult for the individual using a trans-femoral prosthesis to walk as efficiently and naturally as someone using a transtibial prosthesis. Polycentric knee: the instantaneous centre of rotation of a polycentric knee changes through the range of motion because of its linkage design. Modern carbon graphite composites are strong. They are especially suited to highly active users and allow walking at faster speeds with lower energy cost. . durable and light weight and allow energy storage and return through the gait cycle. Swing control can be improved by use of friction and resistance devices as detailed below. the knee must remain stable as the body weight rolls forward over the prosthetic foot during the stance phase of gait. eversion and rotation help to reduce the torque forces on a patient’s residual limb. single axis or polycentric knee with the addition of a locking mechanism that locks automatically when ORTHOPAEDICS AND TRAUMA 24:4 282 Ó 2010 Elsevier Ltd. controlled using rubber bumpers. Multiaxial feet allow greater movement in more planes through rubber bumpers e inversion. These feet are particularly useful for patients who wish to walk on uneven ground or play sports such as golf. This is determined by its mechanical properties (friction or resistance). the prosthetic knee should flex and extend smoothly through the swing phase of gait at a rate compatible with the patient’s walking speed. silicone/gel liner with pin Low profile SACH or multiaxial foot Insole or silicone foot High activity Free hip with spring control Free Knee Single axis with dual hydraulic control or microprocessor control Polycentric with hydraulic control Vacuum or liner suspension Energy storing or multiaxial foot Silicone or gel liner with pin or vacuum Low profile energy storing foot Silicone foot with carbon fibre sole plate Hip disarticulation or hemi-pelvectomy Trans-femoral Normal residual limb Long residual limb Suspension Trans-tibial Suspension Symes Partial foot Table 4 shape allows self suspension. Low profile feet. Single axis knees: a knee with a simple hinge construction that allows free movement through the swing phase and stability in stance through the positioning of the knee with respect to the weight line and muscular control. vacuum or liner suspension Single or multiaxial foot Supracondylar elastic sleeve. To this end many manufacturers now provide a prosthetic foot for a trial period for patients. light weight. The major categories below describe how various prosthetic knees meet these requirements. If a patient is not active enough and does not load the foot.AMPUTATIONS AND PROSTHETICS Lower limb prosthetic prescription Prosthetic limb prescription Predicted ability level Low activity Locked hip Locked knee Single axis Polycentric Auxiliary suspension SACH foot Supracondylar or cuff Wooden foot or bootee Insole with foam insert Medium activity Free hip with spring control Free knee Single axis with weight activated or pneumatic control Polycentric with friction or pneumatic control Auxiliary. These characteristics enhance stance phase stability.15 As there are many of these feet available with varying stiffness. Feet: prosthetic feet are classified into four main groups. either of simple construction or more dynamic materials are available for ankle disarticulation or Symes patients. With modern developments there are now many feet that provide more than one function. It provides some shock absorption and quickly attains a stable foot flat position e an important characteristic for high level amputees. Dynamic feet are becoming more common as materials develop and prices drop. It remains a commonly used foot because of its simplicity. single axis. however the bulk of the bony end and distal displacement of the prosthetic joint result in restriction on the choice of components and a less than ideal cosmetic result for many patients. lead to a relative shortening of the shin through stance and allow the shin to tuck beneath the thigh when sitting. inherent stability and durability. The single axis foot incorporates a joint to simulate ankle movement. Secondly. It is light weight and durable with low maintenance. Prosthetic knee joints have two functions. it is crucial to match patients with the optimal foot for their activities. Locking knees: a basic.

18. ideally together in a formal goal setting meeting. allowing a swing phase that more closely simulates normal gait. although both types require regular maintenance. The goal must be relevant to the patient in order for them to be motivated to achieve it. including knees. but not all. Goals should be regularly reviewed with the patient to document progress. Outcome measures Outcome measures are used in rehabilitation for two main purposes. In older dysvascular amputees who often require this level of stability it has been found that the use of a locking knee increases walking speed and prosthetic use compared to a free knee. The most advanced microprocessor controlled knees now have “intelligent” technology that enables them to adapt to the individual’s gait over time through the use of on board microprocessors. Objective criteria by which success can be measured should be stated eg to be able to walk 10 m using one walking stick. their family and relevant clinicians involved in their rehabilitation. To be realistic a patient must be willing and able to achieve the goal with the personal and healthcare resources available. which increases with the speed of compression. to walk 10 m with two sticks by 6 weeks. Happily. For these individuals goals that focus on independent wheelchair skills and adaptations to their environment to facilitate these will be most appropriate. many patients adjust well to their disability e many will not even use or like the term disabled. The enhanced function comes with a cost e increased weight. At present they are not routinely used in the NHS because of limited evidence to indicate superior function and prohibitive costs. A time frame should be attached to the goal and long-term goals should be broken down into their constituent short-term goals. or a whole service. The composition of the multidisciplinary team at different amputee rehabilitation centres across the UK varies with some. psychological and environmental barriers. Realistic/Relevant and Timely. Pneumatic knee units: the development of knee units with valve systems containing air or oil has provided knees that offer prosthetic users a varied cadence capability. The goal must be well defined (specific) and clear to the patient. Measurable. All rights reserved. resisting unwanted flexion. Hydraulic knee units: the use of hydraulic fluid provides a frictional resistance. There are many outcome measures commonly used in the field of amputee rehabilitation. They may also be applied to evaluate the effect of an intervention on an individual eg measuring walking speed before and after changing a knee component. Some knee units now offer both swing and stance phase control through hydraulic resistance to knee flexion during weight bearing (yield function) along with the ability to lock the knee in desired flexion angles. Microprocessor technology: the use of computerized components. powered by batteries. At the individual level they can be used to guide achievable goal setting and document a single patient’s progress. The aim is to allow patients with trans-femoral amputations a more natural gait. valid (measuring what it intends to) and responsive to change over time. Most rehabilitation services use the SMART approach to goal setting: Specific. such as physiotherapy. with adjustment of the channel sizes affecting the rate of swing. An outcome measure should be easy to use by clinicians and acceptable to the patient. pneumatic and servo motors. but adds weight and requires frequent maintenance. natural step over step pattern on stairs and slopes and the ability to tailor the knee for specific functions. as well as having ORTHOPAEDICS AND TRAUMA 24:4 283 Ó 2010 Elsevier Ltd.19 Social and environmental factors Participation Goal setting Goal setting is central to any rehabilitation process and ensures that the various members of the multidisciplinary team are working with the patient and their family towards a common aim. The control is less precise than with hydraulic units. All goals should be tailored to that individual to reflect their strengths and weaknesses as well as their personal objectives. Not all amputees will be suitable for. This allows greater confidence over uneven ground. with lower energy expenditure and there has been a proliferation of research surrounding these technologies. The goal should be achievable taking into account the potential physical. Clinical psychologists. maintenance needs and costs. Goals should be discussed and agreed with the patient. It should also be reliable (producing consistent findings). however the psychological impact of limb loss should not be under estimated. but pneumatic systems weigh and cost less.16. For example a patient may wish to walk 20 m with one stick to the local shop within 3 months. although this is not always practical. There is no available cure and their friends and family may perceive them differently.AMPUTATIONS AND PROSTHETICS the knee is extended. At the service level outcome measures may be used to appraise the effectiveness of a specific intervention. for example skiing or horse riding. to guide service development through the use of audit and act as evidence of cost-effectiveness and quality to commissioners. Achievable. both financial and to the patient in terms of additional weight and the need to recharge limbs daily. to walk 20 m with one stick by 10 weeks. The pneumatic knee uses air to provide resistance through swing phase. In order to achieve this they first need to achieve the following short-term goals: to be able to independently don and doff the prosthesis by 4 weeks. ankles and feet is developing rapidly. hydraulic. remains extended during walking and can be released for sitting. to walk 10 m with one stick by 8 weeks. . their family and health The surgical removal of a limb is only the start of a long journey for patients e if provided with a prosthesis they will have a lifetime of adjustments and repairs necessitating regular attendance at their local prosthetics service. professionals involved in their care. Table 5 illustrates examples of different goals for each level of activity and amputation. It is useful for patients who require stance phase stability. centres employing a counsellor or clinical psychologist. ensure that they are still relevant and set new goals if appropriate.17 Weight activated stance control knees: the stance control knee incorporates a braking mechanism that is activated when weight is applied during stance. or wish to use a prosthetic limb. both generic and amputee specific.

Amputation is not a failure and deserves skill and attention to achieve the best possible result for the patient. allowing sufficient space for prosthetic components together with enough leverage for the residual limb to activate the components. Good family support. ORTHOPAEDICS AND TRAUMA 24:4 284 Ó 2010 Elsevier Ltd. Whilst some of these patients have genuine physical or technical problems there are others who will have psychological issues. All rights reserved.AMPUTATIONS AND PROSTHETICS Goal setting by activity and amputation level Table 5 specialist counselling skills. Amputee rehabilitation centres with a counselling service report a reduction in demand for appointments from these high attending users and access to a specialist counselling should be seen as complementary to the work of the other clinicians in an amputee’s rehabilitation. referral to prosthetic services for information can be made then. Environmental factors also play a part in successful Key learning points C C C Level and length e where possible amputation surgery should save as many joints as possible and be in the middle third of the long bone. with the daily process of putting a limb on or with the extra effort required for walking. If a congenital deformity or absence is detected at a 20-week scan. then successful use of a prosthesis will become increasingly difficult and unlikely. full involvement in their rehabilitation and attending patient led groups can all help.4 Patient motivation is crucial to the rehabilitation process e if a patient has no reason to comply with their early exercise routine. . As long as possible isn’t always best! Early referral e patients with elective amputations benefit from pre-amputation consultation to guide realistic expectations. Early rehabilitation assessment and intervention have many benefits and referral should be made at or before surgery. A survey by the National Audit Commission (UK) found that 11% of users account for half the demand for repair or adjustment appointments. are often also involved in the psychological management of phantom pain and post-traumatic stress disorder in this population.

12: 108e11. Abbott CA. deserves as much thought and attention as possible to optimize the post-surgical outcome. 2006: 5e8. Guiterrez R. S47: 103e4. Report. Tenant A. Artificial lower limbs: a report on the supply of artificial lower limbs in the United Kingdom. Jensen TS. 2006. providing support at work or returning to driving. 2 Amputee Statistical Database for the UK. Elsevier. London: Her Majesty’s Stationary Office. We hope this article will go some way to equipping you with knowledge of life after surgery and in turn help your patients. 2002. O’Connor RJ. Orthotics and prosthetics in rehabilitation. Noreng MF. Neumann V. A REFERENCES 1 Lusardi MM. you may view amputation as a failure of other reconstructive efforts.AMPUTATIONS AND PROSTHETICS rehabilitation e whether improving access at home. Furniss D. 14 Vanross ER. Ilkjaer S. Therapy for amputees. 4 Audit Commission National Report. 350(9088): 1353e7. 11 Dawson I. “Fully equipped”. patient support groups and information services can provide assistance in accessing appropriate equipment and information and should form an integral part of amputee rehabilitation centres. 3 The Monopolies and Mergers Commission. UK: CW Print Group. Pain 1988. Clinical guidelines for the pneumatic post amputation mobility aid (Mark 11). ´ 6 Bach S. 18: 12e7. 8 Neumann V.co. Middleton C. The SIGAM mobility grades: a new population specific measure for lower limb amputees. J Prosthet Orthot 2006. Nizio H. The biomechanics of trans-femoral amputation. Van de Ven C.nasdab. Energy expenditure during ambulation in dysvascular and traumatic below knee amputees: a comparison of five prosthetic feet. Parsons J. Patient preference and gait efficiency in a geriatric population with transfemoral amputation using a free-swinging versus a locked prosthetic knee joint. 10 Engstrom B. Kodavli K. The Scottish Physiotherapy Amputee Research Group. 19 Ryall NH. 1989. 17 Devlin M. O’Connor R. Conclusion As surgeons. Scott H. Neumann VC. Churchill Livingstone. Dawes D. Prosthet Orthot Int 1994 Apr. Bhakta B. 2005/06. Perry J. 2008. Stills M.uk. Preparation for. Prosthet Orthot Int 2006. Divers C. Davies V. Powers CM. however for the patient this is the start of a new chapter in their life where they will have to adjust to limb loss and return to as near normal life as possible. Bush D. from the specialist team if possible. London: Chartered Society for Physiotherapy. Occupational therapists. Becker E. Disabil Rehabil 2003 Aug 5. Phantom limb pain in amputees during the first 12 months following limb amputation after preoperative lumbar epidural blockade. It is important to give a realistic view e an overly positive outlook can be harder to deal with than a negative one. 90: 610e7. 15 Torburn L. 13 Salawu A. Sinclair LB. Effects of early mobilization on unhealed dysvascular transtibial amputation stumps: a clinical trial. 41: 593e603. 5 Gottschalk FA. ORTHOPAEDICS AND TRAUMA 24:4 285 Ó 2010 Elsevier Ltd. Arch of Phys Med Rehabil 2002. Energy expenditure and cardiac response in above-knee amputees while using prostheses with open and locked knee mechanisms. as it will lead to disappointment with the realities of life with an artificial limb. 12 Sansam K. Campbell JE. Tjellden NU. . 16 Isakov E. Hancock A. highlighting the importance of clear advice. Randomised trial of epidural bupivacaine and morphine in prevention of stump and phantom pain in lower limb amputation. Johnson S. Arch Phy Med Rehab Apr 2009. Susak Z. Colman D. Nielsen CC. Stump ulcers and continued prosthetic limb use. Cryoprobe treatment for painful neuromas in amputees. Unia P. www. Bhakta BB. 7 Nikolajsen L. 25: 833e44. 17 May 1999. Lancet 1997. 32: 111e9. 18 Condie E. Surveys of amputees attending prosthetic centres found that 20% thought they were not given a clear explanation of treatment prior to amputation. J Rehabil Med 2009. Treweek S. 18: 13e45. 30: 279e85. 33(3): 297e301. J Rehabili Med 2008. Blundell A. Eyres SB. J Rehabil Res Dev 1995. whether or not it is life saving. Lower limb prosthetic outcome measures: a review of the literature 1995 to 2005. Predicting walking ability following lower limb amputation: a systematic review of the literature. Scand J Rehabil Med Suppl 1985. 83: 246e9. 9 Broomhead P. Neumann V. Christensen JH. all will have an impact. and carrying out of amputation surgery. All rights reserved. 3 edn. Clinical guidelines for the pre and post-operative physiotherapy management of adults with lower limb amputation. Gilbertson A.

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