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Chapter 24A - Atlas of Limb Prosthetics: Surgical, Prosthetic, and Rehabilitation Principles

Special Considerations: Fitting and Training the Bilateral

Lower-Limb Amputee
Douglas G. Smith, M.D.
Ernest M. Burgess, M.D.
Joseph H. Zettl, C.P.
The bilateral lower-limb amputee has throughout recorded medical history presented a special
challenge for the rehabilitation team to provide a degree of mobility that would allow a more
normal place in society. Persons with high-level amputations or congenital limb deficits that
present a similar functional loss can occasionally walk without a prosthesis by using crutches
and a swing-through gait. This requires very good trunk and upper-body strength, sense of
balance, and muscle control. Such ambulation is seen very occasionally in children and young
adults. In most cases, assistive devices are necessary to stand and walk. Many simple as well
as ingenious means have been used by the amputee to move from place to place. Often the
amputees self-designed and made devices that best suited their needs.
The surgeon, the prosthetist, and the rehabilitation team have at their disposal today a wide
variety of prosthetic and assistive aids for providing comfortable standing and walking. The
remarkable degree of functional restoration now possible can often permit the bilateral leg
amputee to participate in a life-style that socially and vocationally overcomes his physical
Bilateral lower-limb amputations are much more frequent currently than in the past largely
secondary to an aging population with an increased incidence of peripheral vascular disease
and diabetes mellitus. Improved medical management is continually increasing life expectancy
throughout the industrialized world. As people live longer, the complications of diabetes,
peripheral vascular disease, and other chronic medical diseases progressively increase the
frequency of lower-limb loss. In 1985, there were 112,500 nontraumatic lower-limb amputations
in the United States, and 50% of these were in patients with diabetes. The 3-year survival
rate after a major amputation for diabetes or vascular disease is about 50% and is essentially
unchanged from the mid-1960s to the early 1980s. Since these disease states are systemic,
studies have shown that approximately 25% of the original group, or about 50% of surviving
patients, can be expected to lose the second limb by 2 to 3 years following the first amputation.
The quality of surgical, medical, and rehabilitative care further results in a life expectancy of
months and often years as a bilateral lower-limb amputee. Mobility by ambulation with
prostheses profoundly improves the quality of life as compared with a wheelchair existence.

Reproduced with
permission from
Bowker HK,
Michael JW (eds):
Atlas of Limb
Surgical, Prosthetic, and
Rehabilitation Principles.
Rosemont, IL, American Academy
of Orthopedic Surgeons, edition 2,
1992, reprinted 2002.
Much of the material in this text has
been updated and published in
Atlas of Amputations and Limb
Deficiencies: Surgical, Prosthetic,
and Rehabilitation Principles
(retitled third edition of Atlas of Limb
Deficiencies), American Academy
or Orthopedic Surgeons. Click for
more information about this text.
Funding for digitization
of the Atlas of Limb
Prosthetics was
provided by the
Northern Plains Chapter of the
American Academy of Orthotists &

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tax-deductible contribution.

There are also an increasing number of bilateral lower-limb amputees as a result of trauma,
especially in war or natural disasters. The current high quality and availability of military and
emergency medical care allows survival for many patients whose severe trauma would have
been fatal in previous decades. Loss of both lower limbs is also encountered in trauma centers
throughout the industrialized world. Motorcycle accidents, pedestrian involvement in car or train
accidents, and severe burns are generally responsible. Most of those sustaining bilateral
traumatic lower-limb amputations are adolescents and young adults. Prosthetic rehabilitation
potential is usually excellent.
Bilateral congenital leg amputations and limb deficiencies encompass a small but often difficult
group. With appropriate prosthetic management, rehabilitation can be surprisingly successful
and rewarding in these infants and children. Even if prosthetic ambulation is not expected to
continue into adult life, the independence and mobility achieved by aggressive prosthetic
rehabilitation in the early years improves the general health and social development of these


Retention of maximum limb length by amputation at the distalmost suitable level is particularly
important for the bilateral amputee. There is absolutely no added benefit to having both lower
limbs amputated at the same level. Even if a patient is a bilateral transtibial amputee, it is not
necessary to have both legs symmetrical, and all length possible that is suitable for prosthetic
fitting should be preserved (Fig 24A-1.). State-of-the-art plastic and microvascular reconstructive
surgery is on occasion justified to maintain residual-limb length. This is particularly true when
the amputations result from burns. Bone lengthening procedures, however, are rarely justified.
The surgical management of these difficult cases requires a full knowledge of the principles of
modern prosthetic management. The amputation site becomes the new interface for human
contact with the environment and must be as functional and comfortable as possible (Fig 24A2.).
Even in the bilateral amputee, there remain a few regions where it is not advisable to amputate,
not only because healing may be compromised but also because prosthetic substitutions are
unsatisfactory at these few levels in the lower portion of the leg. These areas include the lower
fifth of the leg down to but just above the Syme-level ankle disarticulation, the very short

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transtibial amputation above the attachment of the patellar tendon, and the very short
transfemoral amputation in the subtrochanteric region. In each of these instances it is usually
better to elect amputation at a higher level to permit improved prosthetic substitution and patient
Although optimum function is usually the primary concern in amputation, the cosmesis of the
prosthetic limb replacement must also be considered. Syme ankle disarticulation and knee
disarticulation levels have a bulbous end and result in a less aesthetic appearance in the final
prosthesis. Patients with high cosmetic expectations might be dissatisfied with these levels
(Fig 24A-3.).
In the geriatric age group, the patient's activity level, ambulatory potential, cognitive skills,
vision, and overall medical condition must be evaluated to determine whether the distalmost
level is really appropriate for the patient. In ambulatory patients, the goal is to achieve healing at
the most distal level that can be prosthetically fit and allow successful rehabilitation. Most
unilateral transtibial amputees who were successful prosthetic ambulators will master bilateral
amputee gait if a transtibial or more distal amputation can be performed on the contralateral
limb. The success of rehabilitation decreases dramatically if transfemoral or higher-level
amputations need to be performed.
In nonambulatory patients, the goal is to obtain wound healing, minimize complications, and
improve sitting balance, transfers, and nursing care. For example, a bedridden patient with hip
and knee flexion contractures might be better served with a knee disarticulation or very long
transfemoral amputation than with a transtibial amputation. On the other hand, a geriatric
patient with a previous transfemoral amputation might be a nonambulator but still have excellent
independent transfers and bathroom skills. If the patient capable of independent transfers
develops contralateral foot gangrene, he might be best served by preserving all possible length
and prosthetic fitting, if the goal is to continue independent transfers and bathroom activities.
Such skills are extremely important in the bilateral amputee and should be given careful
preoperative evaluation, even in nonambulatory patients. Careful preoperative assessment of the
patient's potential and setting realistic goals can help direct surgical level selection and
postoperative rehabilitation wisely.


Rapid prosthetic rehabilitation of the multiple-limb amputee ensures the best results in returning
to an active, independent life-style. Speed of recovery is frequently indicative of how well the
patient will be able to perform predetermined rehabilitation goals. This is particularly important in
the management of the majority of amputees we are treating today, the elderly. The
psychological and economic benefits to this patient approach are also quite appreciable.
Contemporary prosthetic fitting of the bilateral lower-limb amputee can be categorized into
immediate postsurgical prosthetic fitting (IPPF), early postsurgical prosthetic fitting, preparatory
prosthetic fitting, and definitive prosthetic fitting. Although managed differently, previous
unilateral amputees who later become bilateral and simultaneous bilateral amputees both
benefit from early rehabilitation with controlled weight bearing.
Improved wound healing, the prevention of contractures, and early mobilization through the use
of rigid dressings dominate the immediate and early phases. Maturation of the residual limb
by comfortably, increasing weight bearing and initial gait training predominate in the preparatory
prosthetic phase. Cosmesis, durability, and final gait training become important considerations
in the definitive prosthetic phase. Increased sophistication of current fitting techniques,
materials, and available componentry make the correct selection and application more critical
than ever before as the patients proceed through these various phases of prosthetic
management and training.

Immediate Postsurgical Prosthetic Fitting

Ideally, IPPF with controlled weight bearing is the initial patient treatment of choice, especially
in the young traumatic amputee. The details and benefits of applying a rigid dressing (i.e.,
plaster of paris socket) with a pylon extension and prosthetic foot in the operating room have
been adequately documented in the literature. The primary consideration is achieving rapid,
optimal wound healing. This is accomplished by controlling postsurgical edema without
restricting circulation. Tissue support minimizes inflammatory reaction and reduces phantom
pain. The psychological benefits are significant as the patient wakes up with a prosthesis in
place of the amputated limb and rehabilitation starts immediately. Carefully controlled static
weight bearing can be initiated the first postoperative day or whenever the patient is physically
capable of tolerating the procedure. Use of a tilt table is necessary for the bilateral amputee,
with bathroom scales or other pressure-monitoring devices utilized to help regulate weight
bearing. As wound healing progresses and is monitored at the various cast change intervals,
weight-bearing increments are also accelerated accordingly. Actual ambulation activities are
delayed until the incisions have healed and sutures have been removed. Patients with
simultaneous bilateral amputations must be advanced more slowly and carefully than the
previous unilateral amputee who can tolerate unrestricted weight bearing on the mature,
previously amputated limb (Fig 24A-4.).
If prosthetic pylons have not been utilized initially, manually applied, simulated weight-bearing
activities are administered by the therapist or the patient himself through the cast (Fig 24A-5.).
The reduction in edema that results from simulated weight bearing decreases postoperative
discomfort. IPPF can be implemented in any hospital setting that has a trained team of
professionals available. The team consists of a surgeon, a prosthetist, a physical therapist, a
nurse, and other auxiliary personnel as might be required.

Early Postsurgical Prosthetic Fitting

Under certain conditions, the surgeon may defer application of a rigid dressing 1 to 3 weeks
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postsurgically to or near the time when sutures are removed from the surgical incision. Although
we prefer immediate use of rigid dressings, to delay until suture removal is very common in the
bilateral amputee. At this stage, considerable postsurgical edema is usually evident, and
residual-limb or phantom pain can be exaggerated in spite of soft compression dressings such
as an elastic bandage or shrinker sock. In all probability, the patient has been restricted to
bed rest or limited to wheelchair mobility, which leads to physical decompensation and muscle
weakness. In a worst-case scenario, wound healing can be compromised as a result of this
The early prosthetic fitting techniques employed are the same as for the IPPF. If considerable
edema is evident at the initial application of the cast socket, frequent cast changes may be
indicated until this condition stabilizes. If a cast socket inadvertently comes off the limb, it
should not be pushed back on. Damage to the residual limb may result with associated pain for
the patient. A new cast socket must be applied without delay.
Removable cast sockets, in our experience, have been unsuccessful. As the name implies,
they are removable and can come off the residual limb at the most inappropriate time. The
need for daily wound inspection contradicts our position of undisturbed tissue support and
immobilization. Removable rigid dressings must be continuously monitored and require the
complete cooperation of a reliable patient. Regular-interval full-cast changes between 7 and 10
days are adequate for dressing changes unless wound problems require more frequent
Soft compression dressings supplemented by an elastic bandage or shrinker sock are less
effective in achieving rapid wound healing. Residual-limb edema associated with discomfort and
phantom pain is frequently evident with this form of patient treatment. It delays the recovery
period unnecessarily and invites further complications in the form of joint contractures and
general physical decompensation, especially in the geriatric patient.

Preparatory Prosthetic Fitting

Preparatory prostheses, also referred to as intermediate or training prostheses, are useful if the
volume of the residual limb is expected to decrease rapidly in the near future or if a gradual
reduction of joint contractures will require repeated prosthetic realign-ment. This is common
in simultaneous bilateral amputees who cannot advance their weight bearing as quickly as
unilateral patients.
Such prostheses are also indicated for evaluating a patients potential to safely ambulate or to
demonstrate to a patient the energy and skill requirements associated with the use of
prostheses. If used in this context, preparatory prostheses are indeed justified and present the
best diagnostic and economic tool for measuring a patient's mobility capabilities. The bilateral
amputee greatly benefits from this approach (Fig 24A-6.).
Component choice is carefully prescribed in consideration of the particular patient's needs.
Likewise, the prosthetic socket configuration as well as design anticipates the patients
requirements and is the critical contact point of the human anatomy and the mechanical
substitute. Patient comfort will make the decisive difference between acceptance and rejection
of the prosthesis and is therefore a high priority.
Whenever possible, the components of choice should be the same as those anticipated for the
definitive prosthesis to minimize the retraining and relearning required. The economics of this
practice are realistic and obvious. It is frequently prudent to utilize definitive foot-shin-knee
components for the preparatory prosthesis and carry them over into the definitive device.
Commercially available, prefabricated, adjustable sockets may warrant consideration in
particular situations when in the opinion of the team this approach is pref-erable.

Definitive Prosthesis
Definitive prostheses are sometimes erroneously called "permanent" or "final" prostheses.
These are misnomers since all prostheses wear out mechanically or require replacement due to
deteriorating fit.
Never before in the history of prosthetics have pros-thetists had so many sophisticated
materials and components at their disposal to serve their patients better and more effectively.
High-strength, lightweight components made from titanium and carbon fibers combined with
sockets fabricated with thermoplastic materials or acrylic resins result in a lightweight
prosthetic construction that reduce energy consumption during ambulation activities. Improved
biomechanical fitting principles and static and dynamic test socket procedures combined
with flexible socket construction further enhance patient comfort and acceptance. Radiographs
or xeroradiography can isolate or pinpoint residual-limb fitting problems. Recent
developments in computer-aided design and computer-aided manufacture (CAD-CAM) open the
door to new and exciting possibilities to better serve the multiple-limb amputee. All this
demands greater knowledge and skills on the part of not only prosthetists but also the entire
clinic team, who are responsible for formulating the prosthetic prescription.
Individual patient needs vary greatly among infants, children, adolescents, adults, athletes, and
active and sedentary geriatric amputees. There are different requirements between males and
females and important considerations to be made for vocational and recreational activities.
Parents, spouses, relatives, and friends of patients also play an important role since they
influence patients' expectations and reactions to their prostheses and management. Each new
patient requires individual assessment and evaluation to determine his exact personal needs.
While many amputation levels are similar or the same, the individual patient requirements are
vastly different and must be accommodated to be effective in the overall, total rehabilitation of
the patient. A patient must learn to walk before he can expect to run, if this is even physically

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Bilateral amputations can be of an equal level such as foot, ankle, transtibial, knee
disarticulation, transfemo-ral, and hip disarticulation, or any combination of the above. Since it
is the surgeon's intent to preserve all joints and all useful length in the residual limb, the
prosthetist is presented with the challenge of varied amputation level combinations where
prosthetic designs must interact effectively.

While statistically a very small group, children with congenital limb deficiencies present major
challenges to the entire rehabilitation team. Depending on the full extent of the anomaly, infants
may face continuous treatment throughout their lifetime to manage the disability. Early
diagnosis, surgical intervention, and prosthetic fitting have been advocated. As a result, infants
are being fitted with lower-limb prostheses as early as 8 months of age or when they attempt to
accomplish a seated or an upright position.
Even high-level amputees as a result of lumbosacral agenesis have been fitted with specially
designed prostheses. The initial prosthetic socket extends to the thorax for stabilization to
allow an upright position and can be fit for sitting as early as 4 to 6 months. The socket is
mounted on a stable platform to which casters can be mounted for mobility. Limited ambulation
is accomplished in time, when the socket is mounted on a swivel walker for self-induced
mobility. Following bilateral hip disarticulations, the prosthetic socket is combined with
cosmetically enhanced thigh-shank-foot components that allow sitting, standing, and some
limited ambulation on the principles of a swivel walker. Often these patients have multiple
medical problems that require continued treatment and monitoring and may interrupt prosthetic
Miniaturized, commercially available prosthetic components are very limited for infants. This
requires the prosthetist to design and custom-fabricate what is needed. Some upper-limb
components such as manually locking elbow joints can be integrated into lower-limb infant
prostheses. Since structural strength requirements are very minimal, plastic tubing can be
utilized in endoskeletal designs and results in very lightweight, cosmetic appliances.
Recently we have switched to aluminum tubing that is fitted into a larger-size tubing, thus
allowing telescoping length adjustments for growth.
Our current, typical, initial knee disarticulation infant prostheses consist of flexible
thermoplastic sockets mounted in rigid frames. This allows for socket replacements due to
growth without remaking the entire prosthesis. Total-contact socket designs using a sock
interface with the classical Silesian bandage or a modified version thereof has been the most
frequent method of suspension. A miniaturized version of the total elastic suspension (TES) belt
has also proved to be an effective option. Any suspension considerations must resolve the
problems of diapers and thus should be moisture resistant and washable. Flexible or rigid pelvic
band and hip joint suspension or shoulder harness suspension is seldom indicated in infants. In
our experience, it is possible to fit select infants with total-contact suction suspension as early
as 18 to 24 months of age. This eliminates most auxiliary suspension needs. The
prerequisite is that parents be able to apply the prosthesis correctly. More frequent socket
replacements as a result of suction socket fittings are not as significant as anticipated and
should not be a deterrent. Recently, the introduction of the hypobaric suspension system has
provided another suspension option. The system utilizes a prosthetic sock that is impregnated
circumferen-tially at the midportion with a narrow band of flexible silicone that forms an effective
seal on the inner socket wall and results in socket suspension. This system is appropriate even
for infants.
The use of stubbies as the initial prosthesis is recommended for all bilateral knee disarticulation
or trans-femoral amputees, regardless of age, who are considered candidates for ambulation
and who lost both legs simultaneously. Stubbies consist of prosthetic sockets mounted
directly over rocker-bottom platforms that serve as feet. The rocker-bottom platforms have a long
posterior extension to prevent the tendency for the patient to fall backward initially. The
shortened anterior portion allows smooth rollover into the push-off phase. As hip flexion
contractures lessen and balance improves, the posterior rocker extensions can be shortened
accordingly. The use of stubbies results in lowering of the center of gravity, and the rocker
bottom provides a broad base of support that teaches trunk balance and provides stability and
confidence to the patient during standing and ambulation. As the patients confidence and
ambulation skills improve, periodic lengthening of the stubbies is permitted until the height
becomes nearly comparable with full-length prostheses, at which time the transition is
attempted. Knee components are usually omitted for infants since stability and balance are still
The majority of infants, children, and young adults with bilateral knee disarticulation or
transfemoral amputations can generate the energy required to ambulate when wearing stubbies
without needing assistive devices such as crutches or canes. Assistive devices may be needed
for safety and support once the patient has accomplished the transition to full-length
prostheses. Such assistive devices severely compromise upper-limb function and should be
avoided where possible since this alone is a major deterrent to using full-length prostheses.
Parents like cosmetically pleasing prostheses, and every effort should be made to achieve this
without sacrificing comfort or function. Lightweight exoskeletal designs are also quite
acceptable for use in infants, and the choice should depend on what is considered most
appropriate for a particular patient and parent.

Most children, including high-level bilateral lower-limb amputees, have very high physical activity
levels. They are encouraged to participate in play, sports, and recreation activities like any other
child. As a result many of the children place profound physical demands on their prostheses.
Prostheses in need of major servicing and repairs are a joy to the entire clinical team, for they
denote a very active, well-adjusted child who is using the prostheses to their maximum
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potential. For this reason, durability must be considered in the design for this active group of
amputees. Fortunately, with the introduction of new petrochemical-based materials that are
lightweight and strong, the challenge of prosthetic durability can be met better today than ever
before. Prosthetic researchers, engineers, suppliers, and manufacturers have finally started to
meet the challenge of providing componentry for this very active group of young children. Some
noteworthy examples of these new developments are the hip disarticulation and trans-femoral
endoskeletal system with adjustable knee friction and extension assist from Otto Bock and the
Child Play Seattle LightFoot from M.I.N.D. The Aqua-Flex, an all-plastic transfemoral pediatric
knee-shin setup from Ford Laboratories in Richmond, British Columbia, Canada, can be used to
make a waterproof prosthesis. Many components are still custom-designed and hand-fabricated
by prosthetists to meet their individual patients needs.
Comfort and control of the prosthesis are directly proportional to good socket retention on the
residual limb. This becomes critical in the bilateral amputee. Thus, it is advisable to use
suction suspension whenever this is possible in both transfemoral and trans-tibial fittings. The
need for slightly more frequent socket replacements is a small price to pay to allow improved
function and comfort for the active youngster.
The use of the silicone suction socket (3S) technique has been reported and expanded to
include all levels of amputation. Hypobaric suspension can also be utilized in children, as
well as the conventional suspension systems such as hip control belts, waist belts, and cuff
suspensions. Unstable knee joints may require the addition of side joints and thigh lacers or, at
a minimum, a patellar tendon supracondylar (PTS) socket design. PTS socket configuration
is also useful for short and very short residual transtibial limbs and where pistoning must be
held to a minimum, such as in skin graft or burn patients. Whatever system is chosen, it must
fill the needs and abilities of the patient and parents without making it technically too complex
and thus frustrating.
Occasionally a patient with bilateral tibial hemimelia is encountered after bilateral Syme ankle
disarticulation or transtibial amputations. Knee instability and flexion contractures are major
concerns that frequently accompany these congenital limb deficiencies. Prosthetic prescription
should include side joints and thigh lacers, not so much to distribute weight as to provide
increased medio-lateral knee stability (Fig 24A-7.). When the knee flexion contracture exceeds
15 to 20 degrees, special socket modifications and techniques are indicated to accommodate
the deformity (Fig 24A-8.). If the congenital limb deficiency is so severe that knee instability or
flexion contractures prohibit prosthetic fitting, then knee disarticulation is required on one or
both limbs (Fig 24A-9.).
As discussed in the infant section, the use of stubbies as the initial prostheses is
recommended for rehabilitation of all bilateral knee disarticulation and transfemoral amputees
who are considered candidates for ambulation and who lost their legs simultaneously. The
majority of children with bilateral knee disarticulation and transfemoral amputations can
generate the required energy to develop ambulatory capabilities by using stubbies without
assistive devices such as walkers, crutches, or canes (Fig 24A-10.). This high performance
level is not always sustainable through adulthood, but diminishes with advancing age when
some become marginal users or abandon the prostheses altogether, except for cosmetic use,
in favor of wheelchair mobility.


This group of amputees frequently proves the prosthetic team wrong when told of physical
limitations associated with multiple amputations. The news media constantly remind us of the
stunning accomplishments of amputee athletes, including bilateral high-level lower-limb
amputees. These runners, swimmers, skiers, rowers, mountain climbers, basketball players,
etc., demonstrate the dangers of stereotyping amputees with outdated classifications.
Experience has proved that patients can excel safely if given the opportunity rather than being
told that they are unable to do so (Fig 24A-11.).
Most bilateral amputees perform these extracurricular recreational activities with conventional
prostheses. A few, more competitive amputee athletes may have special prostheses designed
to aid their accomplishments in competitive sports events. There is an abundance of materials
and componentry available from which to select what is most suitable for a particular amputee.
They should be allowed to evaluate different socket designs, knee components, and feet to
determine the best functional combination for their needs. This is an expensive and timeconsuming process but ensures the best results. Similarly, refinements of socket fit through
repeated static and dynamic test socket procedures, including proper alignment of
components, makes for more functional prostheses (Fig 24A-12.).
Suction suspension, including semiflexible transtibial and transfemoral sockets, is preferable for
bilateral amputees, so long as the amputee is able to don and doff the prostheses effectively
without assistance. Flexible brim, ischial containment transfemoral sockets provide more
comfort during ambulation and when seated by providing increased clearance in the perineum. It
must be noted, however, that there are numerous successful bilateral transfemoral amputees
utilizing quadrilateral or modified quadrilateral suction or semisuction prostheses. Either these
patients have not yet made the transition to ischial containment socket designs, or they have
tried the transition but prefer to remain with their previous socket designs (Fig 24A-13.).
Early flexible inner sockets lacked durability. Surlyn and certain polyethylenes cracked and
buckled under rigorous use and required frequent replacement. Improved working techniques
and better materials have reduced these problems and given the prosthetist a wider choice of
options. The 3S socket design, including the Icelandic Roll-on Suction Socket (ICE-ROSS)
system, provides excellent suspension and minimizes the problem of excessive perspiration of
the residual limbs that is commonly encountered in bilateral prosthesis use.
Dynamic-response foot and ankle components have a profound impact on socket comfort and
the functional capabilities of all lower-limb prosthetic users. Amputees have noted improvement

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in proprioceptive feedback; improved negotiation of inclines, declines, and uneven terrain; as

well as improved impact absorption and reduction of torque and shear forces. All of these
enhance stability and control of prostheses and improve gait. Special foot alignment and
resistance is required for the bilateral amputee for security and balance. There is an abundance
of knee joint components available that aid in stability and function. For maximum durability,
exoskeletal design has the advantage over endoskeletal systems. For cosmetic appearance,
the endoskeletal system has a distinct advantage and is therefore favored by many females.
Postfitting realignment procedures are performed much more conveniently and expediently with
endoskeletal designs than with exoskeletal systems that require major labor-intensive reworking
procedures to achieve alignment corrections.
Bilateral young transtibial amputees usually become excellent ambulators with a relatively
normal gait without the use of external aids. Similarly, persons with bilateral partial-foot
amputations, Syme ankle disarticulations, or a combination of these levels accomplish a nearnormal gait. Knee disarticulation or transfemoral amputees with contralateral transtibial or more
distal amputation also become accomplished ambulators but frequently prefer a cane or other
assistive device. Most bilateral amputees who have lost one knee limit their daily ambulation
activities and have sedentary jobs.
The simultaneously acquired bilateral knee disarticulation or transfemoral amputee requires
fitting with stubbies as the initial prostheses, as previously discussed. In our experience, most
adults with acquired bilateral transfemoral amputations fail to become consistent wearers of fulllength prostheses but continue the use of stubbies for their daily ambulation activities. They
may elect to wear the full-length prostheses for special events or cosmetic reasons only. The
longer lever arm, balanced thigh musculature, and end-bearing capacity of the knee
disarticulation makes bilateral full-length prosthetic use easier than for the bilateral transfemoral amputee, but the principles and training are very similar (Fig 24A-14.). The
accomplished user of bilateral transfemoral prostheses typically uses a cane and has midthigh
or longer amputation levels. This patient was usually involved in recreational or sports activities
prior to the amputations, is physically slim and fit, and has high endurance and good
motivation. Full-length prostheses are usually designed to shorten the patient's stature slightly
because balance is improved by lowering the center of gravity (Fig 24A-15.). Use of a stancecontrol or manual-locking knee is reserved for the shorter of the residual limbs. Different knee
mechanisms can and should be utilized as required, but they must be tested and evaluated
during trial ambulation. Foot and ankle components should be of the same type and function for
both limbs and have a stiffer plantar flexion resistance than is required in unilateral cases.
Larger foot size may improve support and stability. The patient must be able to achieve a
seated and standing position independently and in less-than-ideal locations. The amputee must
also be trained to return to the standing position from the ground as occasionally would be
required after a fall. Bilateral transfemoral prosthetic users require a great deal of gait training by
a qualified physical therapist. Negotiation of stairs, inclines, declines, and uneven terrain are
complex challenges that must be learned and practiced by the patient to become an
accomplished ambulator (Fig 24A-16.).
There are some possible variations in the rocker bottoms of stubbies. The use of SACH feet
with the toes pointing posteriorly has been advocated by some for a smoother gait. We have
utilized rocker bottoms incorporating the Greissinger foot multiaxial ankle system (Fig 24A-17.)
and more recently the Flex Walk Foot fitted to tennis shoes. One triple amputee with a very
short transfemoral amputation on one side is capable of briskly walking 2 miles daily for
exercise. He prefers stubbies over full-length prostheses, which require much higher energy
output, are cumbersome, slow him down, and instill a constant fear of falling (Fig 24A-18.). This
experience is very common with the use of full-length transfemoral prostheses and restricts the
majority to ambulation with stubbies only.
Adults with acquired bilateral hip disarticulation rarely become effective ambulators, but they
still may request special-purpose prosthetic fittings. Specially designed and fitted sockets to
allow for more comfortable seating can be provided. Full-length functional prostheses are
primarily for cosmetic appearance while seated in a wheelchair, but it is possible for the patient
to stand in these prostheses and initiate voluntary mobility on the principles of a swivel walker.
A particularly strong patient can also accomplish a swing-through gait with the aid of
crutches (Fig 24A-19.).

The great majority of bilateral lower-limb amputees today are the elderly who lose their limbs
secondary to diabetes and vascular disease between the ages of 55 and 95 years. In general,
dismissing these patients as poor prosthetic candidates is a grave mistake and compromises
the rehabilitation potential when immediate postsurgical treatment is delayed. Lack of exercise
and mobility will encourage joint contractures, weaken the patient, cause loss of independence,
bring on depression, and may even become life-threatening. No patient group benefits more
from immediate postsurgical prosthetic fitting, including early fitting of preparatory or definitive
prostheses, than the geriatric bilateral amputee. The challenge of rehabilitating these patients is
frequently complicated by the presence of other illnesses. Diabetes, chronic infection, kidney
disease, cardiovascular disease, respiratory disease, arthritis, and impaired vision are
complicating factors that require careful consideration when evaluating patients. Delayed wound
healing, slowly healing lesions, and neuropathy warrant additional consideration. Of these
complicating factors, diabetes appears to be the leading cause of second limb loss.
Fortunately, the time interval between the first and second limb loss, which can be months or
perhaps years, makes learning to ambulate easier for the patient than if both limbs are lost
simultaneously (Fig 24A-20.). Chronologic age alone should not determine whether an amputee
is a prosthetic candidate. A 90-year-old patient can be in better physical shape than a 50-yearold and use prostheses accordingly. While the patient must be able to understand and follow
instructions for proper use of the prosthesis, this may not be always the case immediately
preceding or following amputation when systemic toxicity from an infected limb may cause the
patient to act temporarily confused or unaware of the ongoing proceedings. Sometimes patients
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are wrongly diagnosed as prosthetic noncandidates and denied prostheses. We must give the
patient the benefit of the doubt and provide at least preparatory prostheses to evaluate
ambulation potential. Even if prostheses are used only to assist in transfer activities, they are
Preoperative and postoperative patient education is an important adjunct to rehabilitation.
Teaching a patient proper hygiene and care of the residual limbs and the prostheses is vital.
Amputee support groups, now available in many localities, are a great benefit to patients in
learning about their disability and in being able to discuss matters with other amputees that
they may be reluctant to discuss with clinic team members. Older patients require much more
time, understanding, patience, and encouragement. They thrive on praise, and even small
improvements give encouragement and aid in progress. They are frequently forgetful and need to
be reinstructed frequently. Spouses and other family members should be encouraged to
participate during fitting and training sessions. Their input is important, and their concerns
should be addressed in detail.
Prosthesis design and componentry must be based on careful individual evaluation of all
pertinent factors. The most sophisticated prosthesis with hydraulic or pneumatic swing-phase
control, rotators or torque absorbers, and energy-storing foot is totally inappropriate if we are
dealing with a marginal ambulator who uses the prosthesis on a very limited indoor basis. Any
type of prosthesis is inappropriate if the patient is unable to don and doff it properly. Bilateral
transfemoral prostheses are too difficult to manage for most geriatric patients and, if requested,
are primarily for cosmetic effect while using a wheelchair. Even stubbies are often too difficult for
this group to master, and it is a very rare exception to find someone willing to try and to
succeed in ambulating with them regularly (Fig 24A-21.). Use of a transfemoral and transtibial
prosthetic combination is limited to only a few very energetic patients and then for only limited
use around the house.
Socket design must be such that the patient can don and doff the prosthesis independently.
For transtibial prostheses, this may require that special pull-on loops be attached to the socket
or liner for patients with arthritis of the hands. Similarly, a patient must be able to properly
install a wedge suspension system in a PTS design, or other alternatives must be utilized. A
neo-prene suspension sleeve is an excellent means of auxiliary socket suspension if the patient
can apply it properly. If the patient cannot handle buckles, Velcro closures should be
substituted. Side joints and thigh lacers are infrequently required for an unstable knee or very
short residual transtibial limb. They greatly complicate donning the prosthesis, and should be
avoided if other alternatives exist. Little frustrations can lead to total rejection of the prostheses
and must be avoided. The basic rule is to keep them as simple as possible.
Although suction socket suspension is the preferred means of suspension, the bilateral geriatric
amputee can seldom master the conventional donning technique. An alternative method that
merits consideration is use of the liquid-powder, wet-fit method, in which the patient liberally
applies a special liquid lubricant that allows donning the prosthesis. This lubricant rapidly dries
into a powder that allows retention of the socket by suction. Another option is to provide
flexible, roll-on silicone liners that allow donning and doffing while seated. Hyperbaric socket
suspension offers another excellent option.
The majority of bilateral geriatric transtibial amputees master ambulation with the aid of a walker
or cane. An amputee with transtibial amputation and a more distal level on the contralateral side
almost routinely achieves ambulatory status with or without a walking aid (Fig 24A-22.).
Prostheses for geriatric amputees should be made as light as possible with contemporary
techniques. They should be of relatively simple design and not contain superfluous components
that may be of questionable benefit to limited ambulators.
Occasionally geriatric patients with bilateral congenital deformities are encountered who have
remained active ambulators. For these rare patients, custom-designed prostheses are required.
Lightweight construction can prolong prosthetic use and ambulation (Fig 24A-23.).


It is noteworthy that Kegel reports the recent development of special dress shoes for amputees
that are very lightweight, flexible, and have a soft compressible heel to dampen impact at heel
strike. The shoes are manufactured by Bally and look like any other regular dress shoe. Kegel
states that "there are shoes available for soccer, tennis, skiing and other special requirements,
but none for prostheses users." This new development remedies this need.

The bilateral lower-limb amputee presents complicated problems for mobility and ambulation.
The tremendous developments of recent years offer these individuals much greater functional
potential. By applying the surgical, prosthetic, and rehabilitation techniques currently available,
the bilateral lower-limb amputee can often achieve a remarkable degree of functional
1. Aitken GT, Frantz GH: The juvenile amputee. J Bone Joint Surg [Am] 1953; 35:659-664.
2. Arbogast R, Arbogast JC: The Carbon Copy II-From concept to application. J Prosthet
Orthot 1988; 1:32-36.
3. Balakrishnan A: Technical note-tilting stubbies. Prosthet Orthot Int 1981; 5:85-86.
4. Banzinger E: Surlyn socket design for the young child. J Assoc Child Prosthet Orthot
Clin 1987; 22:21.
5. Baumgartner R, Langlotz M: Amputee stump radiology. Prosthet Orthot Int 1980; 4:97100.
6. Berlemont M: Notre experience de l'appareillage precoce des amputes des membres
inferieurs aux establissements Helio-Marins de Berck. Ann Med Phys 1961; 4:4.
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7. Berry D: Composite materials for orthotics and prosthetics. Orthot Prosthet 1987; 40:38.
8. Bild DE, Selby JV, Sinnock P, et al: Lower -extremity amputation in people with
diabetes: Epidemiology and prevention. Diabetes Care 1989; 12:24-31.
9. Bodily KC, Burgess EM: Contralateral limb and patient survival after leg amputation. Am
J Surg 1983; 146:280-282.
10. Boontje AH: Major amputations of the lower extremity for vascular disease. Prosthet
Orthot Int 1980; 4:87-89.
11. Bray J: Total Contact Plastic Suction Socket Manual, ed 6. Los Angeles, UCLA
Prosthetic and Orthotic Education Program, 1981.
12. Breakey JW: Prefabricated below-knee sockets for the maturing stump. Bull Prosthet
Res 1973; 19:42-51.
13. Burgess EM, Poggi DL, Hittenberger DA, et al: Development and preliminary evaluation
of the VA Seattle foot. Rehabil Res Dev 1985; 22:75.
14. Burgess EM, Romano RL, Zettl JH; The Management of Lower Extremity Amputations:
Surgery, Immediate Postsurgical Prosthetic Fitting, Rehabilitation, Bulletin TR 10-6.
Washington, DC, US Government Printing Office, 1969.
15. Burgess EM, Romano RL, Zettl JH, et al: Amputations of the leg for peripheral vascular
insufficiency. J Bone Joint Surg [Am] 1971; 53:874-890.
16. Campbell J, Childs C: The SAFE foot. J Prosthet Orthot 1980; 34:3.
17. Couch NP, David JK, Tilney NL, et al: Natural history of the leg amputee. Am J Surg
1977; 133:469-473.
18. Dankmeyer CH Jr, Doshi R: Prosthetic management of adult hemicorporectomy and
bilateral hip disarticulation amputees. Orthot Prosthet 1981; 35:11-18.
19. Ebskov G, Josephsen P: Incidence of reamputation and death after gangrene of the lower
extremity. Prosthet Orthot Int 1980; 4:77-80.
20. Ekus L: Total suction for toddlers too! J Assoc Child Prosthet Orthot Clin 1987; 22:20.
21. Evans WE, Hayes JP, Vermilion BD: Rehabilitation of the bilateral amputee. / Vase Surg
1987; 5:589-593.
22. Fillauer C: A patellar-tendon-bearing socket with a detachable medical brim. Orthot
Prosthet 1971; 25: 26-34.
23. Fillauer CE, Pritham CH, Fillauer KO: Evolution and development of the silicone suction
socket (3S) for below-knee prostheses. J Prosthet Orthot 1989; 1:92-103.
24. Fishman S, Edelstein JE, Krebs DE: Icelandic-Swedish-New York above-knee prosthetic
sockets: Pediatric experience. J Pediatr Orthop 1987; 7:557-562.
25. Frantz CH, Atken GT: Complete absence of the lumbar spine and sacrum. J Bone Joint
Surg [Am] 1967; 49:1531-1540.
26. Gerhardt JJ, King PS, Fowlks EW, et al: A device to control ambulation pressure with
immediate postoperative prosthetic fitting. Bull Prosthet Res 1971; 10:153-160.
27. Gerhardt JJ, King PS, Zettl JH: Amputations, Immediate and Early Prosthetic
Management. Stuttgart, West Germany, Hans Huber Publishers, 1982.
28. Gottschalk FA, Sohrab K, Stills M, et al: Does socket configuration influence the
position of the femur in above knee amputation? J Prosthet Orthot 1989; 2:94-102.
29. Grimm Z: Physical management and functional restoration of the lower extremity
amputee, in Moore WS, Mal-one JM (eds): Lower Extremity Amputation. Philadelphia,
WB Saunders Co, 1989, pp 229-245.
30. Harris RI: The history and development of Syme's amputations. Artif Limbs 1961; 6:4.
31. Hoyt C, Littig D, Lundt J, et al: The UCLA CAT-CAM Above Knee Socket, ed 3. Los
Angeles, UCLA Prosthetics Education Research Program, 1987.
32. Huang C, Jackson JR, Moore NB, et al: Amputation: Energy cost of ambulation. Arch
Phys Med Rehabil 1979; 60:18-24.
33. Irons G, Mooney V, Putnam S, et al: A lightweight above-knee prosthesis with an
adjustable socket. Orthot Prosthet 1977; 31:35.
34. Jendrzrjezk DJ: Flexible socket systems. Clin Prosthet Orthot 1985; 9:27-30.
35. Keagy BA, Schwartz JA, Kotb M, et al: Lower extremity amputation: The control series.
J Vasc Surg 1986; 4:321-326.
36. Kegel B: Prostheses and assistive devices for special activities, in American Academy
of Orthopedic Surgeons: Atlas of Limb Prosthetics, Surgical and Prosthetic Principles.
St Louis, Mosby-Year Book, 1981.
37. Kegel W: The prosthetic shoe. Orthop Technik 1991; 00:449-451.
38. Kegel B, Moore AJ: Load cell, a device to monitor weight bearing for lower extremity
amputees. Phys Ther 1977; 57:652-654.
39. Kegel B, Webster JC, Burgess EM: Recreational activities of lower extremity amputees:
A survey. Arch Phys Med Rehabil 1980; 61:256-264.
40. Kokegei D, Dotzer R: Prosthetic management of the lower limb after traumatic
amputation. Orthop Technik 1991; 42:434-440.
41. Kruger LM: Lower limb deficiencies, in American Academy of Orthopedic Surgeons:
Atlas of Limb Prosthetics, Surgical and Prosthetic Principles. St Louis, Mosby-Year
Book, 1981, pp 522-552.
42. Kruger LM: The use of stubbies for the child with bilateral lower-limb deficiencies. InterClin Info Bull 1973; 12:7-15.
43. Kuchler-O'Shea R, Schwartz M: Prosthetic training of a three-year-old acquired
quadrimembral amputee. J Assoc Child Prosthet Orthot Clin 1987; 22:81-84.
44. Lambert CN, Hamilton RC, Pellicore RJ: The juvenile amputee program: Its social and
economic value. J Bone Joint Surg [Am] 1969; 51:1135-1138.
45. Lehneis HR: A thermoplastic structural and alignment system for below-knee
prostheses. Orthot Prosthet 1974; 28:23-29.
46. Lehneis HR, et al: Prosthetic Management for High Level Lower Limb Amputees. New
York, Institute of Rehabilitation Medicine, 1980.
47. Lippert FG III, Burgess EM, Starr TW: Physiologic suspension factors in below-knee
amputees evaluation. J Rehabil Res Dev 1983; p. 5.
48. Long IA: Normal shape-normal alignment (NSNA) above-knee prosthesis. Clin Prosthet
Orthot 1985; 9:9-14.
49. Macfarlane PA, Nielsen DH, Shurr DG, et al: Gait comparisons for below-knee amputees
using a Flex-Foot versus a conventional prosthetic foot. J Prosthet Orthot 1991;3:150161.
converted by W

50. Malone JM, Moore W, Leal JM, et al: Rehabilitation for lower extremity amputation. Arch
Surg 1981; 116:93-98.
51. Malone JM, Moore WS, Goldstone J, et al: Therapeutic and economic impact of a
modern amputation program. Bull Prosthet Res 1979; 16:1.
52. Manella KJ: Comparing the effectiveness of elastic bandages and shrinker socks for
lower extremity amputees. Phys Ther 1981; 61:334-337.
53. Marquardt E: The multiple limb-deficient child, in American Academy of Orthopedic
Surgeons: Atlas of Limb Prosthetics, Surgical and Prosthetic Principles. St. Louis,
Mosby-Year Book, 1981, pp 627-630.
54. Marshall K, Nitschke R: Principals of the PTS BK prosthesis. Orthop Prosthet Appliance
J 1967; 21:33.
55. Mauch HA: Stance control for above-knee artificial legs: Design consideration in the S-NS knee. Bull Prosthet Res 1968; 10:61-71.
56. Mazet R, Schiller FJ, Dunn OJ, et al: The Influence of Prostheses Wearing on the
Health of the Geriatric Amputee , Project 431. Washington, DC, Office of Vocational
Rehabilitation, Department of Health, Education and Welfare, 1963.
57. McCollough NC, Jennings JJ, Sarmiento A: Bilateral below the knee amputation in
patients over fifty years of age. J Bone Joint Surg [Am] 1972; 50:1217-1223.
58. Mensch G: Physiotherapy following through-knee amputation. Prosthet Orthot Int 1983;
59. Mensch G, Ellis P: Physical therapeutic management for lower extremity amputees, in
Bannerjee SN (ed): Rehabilitation Management of Amputees. Baltimore, Williams &
Wilkins, 1982, pp 165-236.
60. Michael JW: Energy storing feet: A clinical comparison. Clin Prosthet Orthot 1987;
61. Mooney V, Snelson R: Fabrication and application of transparent polycarbonate sockets.
Orthot Prosthet 1972; 26:1-13.
62. Motlock WJ, Elliott J: Fitting and training children with swivel walkers. Artif Limbs 1966;
63. Mooney V, Harvey JP, MacBride E, et al: Comparison of postoperative stump
management: Plaster vs soft dressings. J Bone Joint Surg [Am] 1971; 53:241-249.
64. Nielsen CC, Psonak RA, Kalter TL: Factors affecting the use of prosthetic services. J
Prosthet Orthot 1989; 1:242-249.
65. Ohio Willow Wood Co. Carbon Copy System HI. Instructional Course and Manual,
Seattle, Wash, 1991.
66. O'Shea R, Schwartz M: Prosthetic gait training for a three-year-old quadrimembral
traumatic amputee. J Assoc Child Prosthet Orthotic Clin 1987; 22:21.
67. Pohjolainen T, Alaranta H, Wikstron J: Primary survival and prosthetic fitting of lower limb
amputees. Prosthet Orthot Int 1989; 13:63-69.
68. Radcliffe C, Foort J: The Patellar-Tendon-Bearing Be-low-Knee Prosthesis. Berkeley,
University of California Biomechanics Laboratory, 1961.
69. Romano RL, Zettl JH, Burgess EM: The Syme's amputation: A new prosthetic approach.
Inter-Clin Info Bull 1972; 9:1-9.
70. Russell JE: Congenital absence of sacrum and lumbar vertebrae: A case report. InterClin Info Bull 1977; 16:7-12.
71. Saadah ESM: Bilateral below-knee amputee 107 years-old and still wearing artificial
limbs. Prosthet Orthot Int 1988; 12:105-106.
72. Sabolich J: Contoured adducted trochanteric-controlled alignment method (CAT-CAM):
Introduction and basic principles. Clin Prosthet Orthot 1985; 9:15.
73. Saunder CG: Computer Aided Socket Design Teaching Manual. Vancouver, Medical
Engineering Research Unit, Shannesse Hospital, 1984.
74. Schuch CM: Modern above-knee fitting practice. Prosthet Orthot Int 1988; 12:77-90.
75. Sowell TT: A preliminary clinical evaluation of the Mauch hydraulic foot-ankle system.
Prosthet Orthot Int 1981; 5:87-91.
76. Staats T: Advances in prosthetic techniques for below knee amputations. Orthopedics
1985; 8:249.
77. Sullivan RA, Celikyol F: Prosthetic fitting of the congenital quadrilateral amputee: A
rehabilitation-team approach to care. Inter-Clin Info Bull 1977; 16:1-6.
78. Swanson VM: Technical note: An alternative below-knee ultra lite technique. J Prosthet
Orthot 1991; 3:191-200.
79. Swedish Flexible Socket Technical Manual. Chattanooga, Tenn, Durr Fillauer Inc, 1985.
80. Van der Waarde T: Ottawa experience with hip disarticulation prostheses. Orthot
Prosthet 1984; 38:29-33.
81. Varnau D, Vinnecour K, Luth M, et al: The enhancement of prosthetic fit through
xeroradiography. Orthot Prosthet 1985; 39:14.
82. Waters RL, Perry J, Antonelli D, et al: Energy cost of walking amputees: The influence
of level of amputation. J Bone Joint Surg [Am] 1976; 58:42-46.
83. Watkins AL, Liao SJ: Rehabilitation of persons with bilateral amputations of the lower
extremities. JAMA 1958; 166:1585-1586.
84. Weiss M: Myoplasty, immediate fitting, ambulation. Presented at the World Commission
on Research in Rehabilitation. Tenth World Congress of the International Society,
Wiesbaden, Germany, 1966.
85. Weiss M: The Prosthesis on the Operating Table From the Neurophysiological Point of
View: Report of Workshop Panel on Lower Prosthetics Fitting. Washington, DC, National
Academy of Sciences, 1966.
86. Whitehouse FW, Jurgensen C, Block MA: The later life of the diabetic amputee: Another
look at the fate of the second leg. Diabetes 1968; 17:520.
87. Wilson AB Jr, Schuch MC, Nitschke RO: A variable volume socket for below knee
prostheses. Clin Prosthet Orthot 1987; 11:11-19.
88. Wolf E, Lilling M, Ferber I, et al: Prosthetic rehabilitation of elderly bilateral amputees.
Int J Rehabil Res 1989; 12:271-278.
89. Wu Y, Brncick MD, Krick HJ, et al: Technical notes: Scotchcast PVC interim prosthesis
for below knee amputees. Bull Prosthet Res 1981; 18:40-45.
90. Wu Y, Flanigan DP: Rehabilitation of the lower-extremity amputee with emphasis on a
removable below-knee rigid dressing, in Gangrene and Severe Ischemia of the Lower
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Extremities. New York, Grune & Stratton, 1978.

91. Wu Y, Keagy RD, Krick HJ, et al: An innovative removable rigid dressing technique for
below-the-knee amputation. J Bone Joint Surg [Am] 1979; 61:724-729.
92. Wytch R, Mitchell CB, Wardlaw D, et al: Mechanical assessment of polyurethane
impregnated fiberglass bandages for splinting. Prosthet Orthot Int 1987; 11:128-134.
93. Zettl JH: Experience with endoskeletal prostheses for lower extremities. Bull Prosthet
Res 1972; 10:52-66.
94. Zettl JH: Immediate postoperative prostheses and temporary prosthetics, in Moore WS,
Malone JM (eds): Lower Extremity Amputation. Philadelphia, WB Saunders Co, 1989, pp
95. Zettl JH: Immediate postsurgical prosthetic fitting: The role of the prosthetist. Am J Phys
Ther 1971; 51:144.
96. Zettl JH, Burgess EM, Romano FL: The interface in the immediate postsurgical
prosthesis. Bull Prosthet Res 1969;8:10-12.
Chapter 24A - Atlas of Limb Prosthetics: Surgical, Prosthetic, and Rehabilitation Principles

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