Atlas of Amputations and Limb Deficiencies 2004. 3 Ed (Atlas de Protesis AAOS) R

Editors
Douglas G. Smith, MD
John W. Michael, MEd, CPO
John H. Bowker, MD
American Academy of Orthopaedic Surgeons
Atlas of Amputations and

Limb Deficiencies
Surgical, Prosthetic, and
. Rehabilitation Principles
Edited by
D ~ John H. Bowker, MD
~ ~
\D A/~ ~)//~ CJ~~u_
~ JJ:- JL/ ~ ~ Hf; Ci ~ f};Jih
. ) ?t-µM
J_2~d-6l l
Board of Directors, 2004
Robert W. Bucholz, MD Published 2004 by the
President American Academy of Orthopaedic Su1'geons
Stuart L. Weinstein, MD 6300 North River Road
First Vice President Rosemont, IL 60018
Richard F. Kyle, MD
Second Vice President Third Edition (Previous editions published under the title Atlas of Limb Prosthetics. )
Edward A. Toriello, MD
Treasurer Copyright ©2004 by the
Leslie L. Altick Ame rican Academy of Orthopaedic SuJgeons
Frederick M. Azar, MD
The material presented in the Atlas of Amputations and Limb Deficiencies: Surgica~ Prosthetic,
Oheneba Boachie-Adjei, MD and Rehabilitation Principles has been made available by the American Academy of Ortho-
Dwight W. Burney III, MD paedic Surgeons for educational purposes only. This material is not intended to present the
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Frank B. Kelly, MD
Some drugs or medical devices demonstrated in Academy courses or described in Academy
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Vernon T. Tolo, MD wishes to use in clinical practice.
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Furthermore, any statements about commercial products are solely the opinion(s) of the au-
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thor(s) and do not represent an Academy endorsement or evaluation of these products. These
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Managing Editor Printed in the USA
Second printing, 2007
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Library of Congress Cataloging- in-Publication Data
Senior Editor
Gayle Murray Atlas of amputations and limb deficiencies: surgical, prosthetic and rehabilitation principles/
Associate Senior Editor American Academy of Orthopaedic Surgeons; edited by Douglas G. Smith, John W. Michael,
MaJy Steermann John H. Bowker.
Manager, Production and Archives p. cm.
David Stanley
Assistant Production Manager Includes bibliographical references and index.
ISBN 0-89203-313-4
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Assistant Production Manager l. Amputation. 2. Amputees--Rehabilitation. 3. Artificial limbs. I. Smith, Douglas G.
Susan Morritz Baim II. Michael, )01111 W. m. Bowker, John H. IV. American Academy of Orthopaedic Surgeons.
Production Coordinator RD553.A87 2004
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iii
Editorial Board
Editors-in-Chief Planning Committee

Douglas G. Smith, MD John H. Bowker, MD
Associate Professor Professor Emeritus
Department of Orthopaedic Surgery and Sports Medicine Department of Orthopaedics and Rehabilitation
University of Washington & Harborview Medical Cepter University of Miami School of Medicine
Director, Prosthetics Research Study Miami, Florida
Medical Director, Amputee Coalition of Ame rica
Seattle, Washington Charles D. Bukrey, MD
Orthopaedic Associates of Grand Rapids
John W. Michael, MEd, CPO Grand Rapids, Michigan
President
CPO Services, Inc. Donald R. Cummings, CP, LP
Portage, Indiana Director, Prosthetics
Department of Prosthetics
John H. Bowker, MD Texas Scottish Rite Hospital for Children
Professor Emeritus Dallas, Texas
Department of Orthopaedics and Rehabilitation
University of Miami School of Medicine John R. Fergason, CPO
Miami, Florida Director, Division of Prosthetics and Orthotics
Department of Rehabilitation Medicine
University of Washington
Pediatrics Section Editor Seattle, Washington
John Fisk, MD
John D. Hsu, MD, FACS
Professor
Emeritus Clinical Professor
Department of Surgery
Department of Orthopaedics
Southern Illinois University School of Medicine
University of Southern California
Springfield, Ill inois
Chief of Orthopaedics (retired )
Rancho Los Amigos National Rehabilitation Center
Associate Editors Downey, California
Donald R. Cummings, CP, LP Susan L. Kapp, CPO
Director, Prosthetics Associate Professor and Director
Department of Prosthetics Prosthetics-Orthotics Program
Texas Scottish Rite Hospital for Children University of Texas Southwestern Medical Center at Dallas
Dallas, Texas Dallas, Texas
John R. Fergason, CPO John W. Michael, MEd, CPO
Director, Division of Prosthetics and Orthotics President
Department of Rehabilitation Medicine CPO Services, Inc.
University of Washington Portage, Indiana
Seattle, Washington
Ramona Okumura, CP, LP
Susan L. Kapp, CPO University of WashingtOD
Associate Professor and Director School of Medicine .
Prosthetics-Orthotics Program Department of Rehabilitation Medicine
University of Texas Southwestern Medical Center at DaUas Seattle, Washington
Da.Uas, Texas
Associate Professor
Department of Orthopaedic Surgery and Sports Medicine
University of Washington & Harborview Medical Center
Director, Prosthetics Research Study
Medical Di rector, Amputee Coalition of America
Seattle, Washington

Dedicated to our wives,
Kathryn Ponto Smith, Linda Michael, and Alice Bowker,
and to our children,
Tina, Ali, and Kevin Smith,
David and Kate Michael,
and Thomas Bowker.
With heartfelt gratitude for their support and forbearance
during the long development of this volume.
v
Contributors
Christopher H . Allan, MD Rickard Branemark, MD, MSc, PhD

Assistant Professor Centre of Orthopaedic Osseointegration
Department of Orthopaedics and Sports Medicine Department of Orthopaedics
Section of Hand and Microsurgery Sahlgren University Hospital
Harborview Medical Center Gothenburg, Sweden
University of Washington School of Medicine
Seattle, Washington Carl D. Brenner, CPO
Director of Prosthetic Research
Randall D. Alley, CP* Michigan Institute for Electronic Limb Development
Director of Clinical Development Livonia, Michigan
Innovative Neurotron ics, Inc
Hanger Orthopedic Group, Inc Kevin M. Carroll, MS, CP
Thou~and Oaks, California Vice President, Prosthetics
Department of Prosthetics
Michael T. Archdeacon, MD, MSE Hanger Prosthetics and Orthotics, Inc.
Director, Orthopaedic Trauma Oklahoma City, Oklahoma
Assistant Professor
Department of Ortliopaedic Surgery Howard A. Chansky, MD
University of Cincinnati Medical Center Associate Professor
Cincinnati, Ohio Department of Orthopaed ics and Sports Medicine
University of Washington School of Medicine
Diane J. Atkins, OTR Chief, Section of Orthopaedics
Clinical Assistant Professor Veterans Affairs Puget Sound Health Care System,
Department of Physical Medicine and Rehabilitation Seattle Division
Baylor College of Medicine Seattle, Washington
Houston, Texas
Dudley S. Childress, PhD
Gary M. Berke, MS, CP Professor and Senior Research Health Care Scientist
Private Practitioner and Adjunct Clinical Instructor Department of Physical Medicine, Rehabilitation,
Department of Orthopaedic Surgery and Biomedical Engi neering
Stanford University Prosthetics Research Laboratory and Rehabilitation Engineering
Redwood City, California Research Program
Northwestern University and VA Chicago Health Care System
Allen T. Bishop, MD Chicago, Illinois
Professor of Orthopedic Surgery, Mayo Medical School
Consultant in Orthopedic, Hand, and Microvascular Surgery Curtis R. Clark, PT
Mayo Clinic University of Miami
Department of Orthopedic Surgery Supervi.s or of Amputee Service
Mayo Foundation Jackson Memorial Hospital
Rochester, Minnesota Miami, Florida
David Alan Boone, CP, MPH Mary Williams Clark, MD
Associate Professor Cl inical Professor of Orthopedics and Pediatrics
Rehabilitation Engineering Centre Sparrow Regional Children's Center
The Hong Kong Polytechnic University Michigan State University
Kowloon, Hong Kong Lansing, Michigan
Roy Bowers, SR ProsOrth David N. Condie, CEng
Lecturer Consultant Clinical Engineer
National Centre for Training and Education in Prosthetics Honorary Senior Lecturer
and Orthotics Department of Orthopaedic and Trauma Surgery
University of Strathclyde University of Dundee
Glasgow, Scotland Dundee, Scotland
John H. Bowker, MD Colleen Coulter-O'Berry, PT, MS, PCS
Professor Emeritus Senior Physical Therapist
Department of Orthopaedics and Rehabilitation Team Leader, Limb Deficiency Program
University of Miami School of Medicine Department of Orthotics and Prosthetics
Miami, Florida Children's Healthcare of Atlanta
Atlanta, Georgia

vi
Donald R. Cummings, CP, LP John R. Fisk, MD

Director, Prosthetics Professor
Department of Prosthetics Department of Surgery
Texas Scottish Rite Hospital for Children Southern Illinois University School of Medicine
Dallas, Texas Springfield, 111inois
Wayne K. Daly, CPO, LPO Charles M. Fryer, MS

Center for Prosthetics Orthotics (deceased)
Seattle, Washington
Robert S. Gailey, PhD, PT
Hans Dietl, PhD Assistant Professor
Managing Director University of Miami School of Medjcine
Otto Bock HealthCare Products GmbH Department of Orthopaedics and Rehabilitation
Vienna, Austria Division of Physical Therapy
Miami, Florida
Kim Doolan
Patient Advocate Clinical Coordinator Brian J. Giavedoni, MBA, CP
Allen Orthotics and Prosthetics Senior Prosthetist
Midland, Texas Orthotics and Prosthetics Department
Children's Healthcare of Atlanta
John P. Dormans, MD Atlanta, Georgia
Chief of Orthopaedic Surgery
Children's Hospital of Philadelphia Gerard L. Glancy, MD
Professor of Orthopaedic Surgery Associate Professor
University of Pennsylvania School of Medicine Department of Ortl10paedic Surgery
Philadelphia, Pennsylvania The Children's Hospital
Denver, Colorado
Paul J. Dougherty, MD
Chief Frank Gottschalk, MD, FRCSEd, FCS(SA)
Department of Surgery Professor
Program Director Department of Orthopaedjc Surgery
Orthopaedic Surgery Residency University of Texas Southwestern Medical Center at Dallas
William Beaumont Army Medical Center Dallas, Texas
El Paso, Texas
Gregory S. Gruman, CP
Joan E. Edelstein, MA, PT President
Special Lecturer The Winkley Company
Department of Physical Therapy Minneapolis, Minnesota
Columbia University
Kenneth J. Guidera, MD
New York, New York
Assistant Cruef of Staff
Dawn M. Ehde, PhD Department of Medical Staff
Assistant Professor Shriners Hospital for Children
Department of Rehabilitation Medicine Tampa, Florida
Unjversity of Washjngton School of Medicine
James T. Guille, MD
Seattle, Washington
Co-Director, Spine and Scoliosis Service
James Engels, MD Department of Orthopaedic Surgery
Pediatric Orthopaedic Con9ultant Alfred I. DuPont Hospital for Children
Center for Limb Differences Wilmington, Delaware
Mary Free Bed Hospital
Brian J. Hartigan, MD
Grand Rapids, Michigan
Clinical Instructor
Biilent Erol, MD Department of Orthopaedic Surgery
Research Fellow Northwestern University, Feinberg School of Medicine
Division of Orthopaedics Chicago, Illinois
The Children's Hospital of Philadelprua
Ph iladelprua, Pennsylvania
Craig W. Heckathorne, MSc
Research Engineer
John R. Fergason, CPO Upper-Limb Prosthetic Specialist
Director, Division of Prosthetics and Orthotics Rehabilitation Engineering Research Program
Department of Rehabilitation Medicine Northwestern University
University of Washington Crucago, Tllinois
Seattle, Wasrungton
Alice L. Kahle, PhD
Psychologist
Department of Psychology
The Children's Hospital of Philadelphia
Philadelphia, Pen nsylvarua

vii
Susan L. Kapp, CPO Sara J. Mulr oy, PhD, PT

Associate Professor and Director Director
Prosthetics-Orthotics Program Pathokinesiology Laboratory
University of Texas Southwestern Medical Center at Dallas Rancho Los Amigos National Rehabilitation Center
Dallas, Texas Downey, Californ ia
S. Jay Kumar, MD John J. Murnaghan, MD, MSc, MA, FRCSC
Clinical Professor of Orthopaedic Surgery Assistant Professor Surgery
Department of Orthopaedic Surgery University of Toronto
Thomas Jefferson University Division of Orthopaedic Surgery
Philadelphia, Pennsylvania Orthopaedic and Arthritic Institute
Toronto, Ontario, Canada
Julian E. Kuz, MD
Upper Extremity Consultant Christopher B. Nelson, CPO
Center for Limb Differences Prosthetist Orthotist
Mary Free Bed Hospital Department of Orthotics and Prosthe.tics
Grand Rapids, Michigan The Children's Hospital
Philadelphia, Pennsylvania
Chris Lake, CPO
Southwest Clinical Director Cara D. Novick, MD
Advanced Arm Dynamics, Inc. Orthopaedic Surgeon
Dallas, Texas Shriners Hospital for Children
Tampa, Florida
S. William Levy, MD
Clinical Professor of Dermatology Mary P. Novotny, RN, MS
Department of Dermatology Nurse, Advocate, and Consultant
University of California School of Medicine Knoxville, Tennessee
San Francisco Medical Center
San Francisco, California E. Anne Ouellette, MD, MBA
Professor, Chief
Terry R. Light, MD Division of Hand Surgery
Dr. William M. Scholl Professor and Chairman Department of Orthopaedics and Rehabilitation
Department of Orthopaedic Surgery and Rehabilitation University of Miamj School of Medicine
Loyola University Chicago Stritch School of Medicine Miami, Florida
Maywood, lllinois
Patrick Owens, MD
Janet G. Marshall, CPO Assistant Professor of Clinical Orthopaedics
Orthotics and Prosthetics University of Mfami School of Medicine
Shriners Hospital for Children Miami, Florida
Tampa, Florida
Thomas Passero, CP
Peter T. McCollum, MCh, FRCSI, FRCSEd President and Clinical Director
Professor of Vascular Surgery LIVINGSKIN® Aesthetic Concerns Prosthetics, Inc
Vascular Unit Middletown, New York
Hull Royal Infirmary
Hull, England Joanna G. Patton, OTR/L
Clinical Occupational Therapist and Instructor
John W. Michael, MEd, CPO* Child Amputee Prosthetics Project
President Shriners Hospital for Chj)dren
CPO Services, Inc. Los Angeles, California
Portage, Indiana
Jacquelin Perry, MD
John M. Miguelez, CP Chief Emeritus, Pathokinesiology Service
President and Senior Clinical Director Professor Emeritus of Orthopaedics, USC
Advanced Arm Dynamics, Inc. Department of Pathokinesiology
Rolling HiJJs Estates, California Rancho Los Amigos National Rehabilitation Center
Downey, California
Michelle D. Miguelez, JD
Redondo Beach, California Michael S. Pinzur, MD
Professor
Walid Mnaymneh, MD Department of Orthopaedic Surgery and RehabiJjtation
Professor of Orthopaedics and Oncology Loyola University Medical Center
Department of Orthopaedics and Rehabilitation Maywood, Illinois
University of Miami School of Medicine
Miamj, Florida Pradip D. Poonekar, MD
Prosthetic Surgeon
Artificial Limb Centre
Pune, India

viii
Charles H. Pritham, CPO Douglas G. Smith, MD*

Practice Manager Associate Professor
Carolina Orthotic and Prosthetic Lab, Inc. Department of Orthopaedic Surgery and Sports Medicine
Hanger Prosthetics and Orthotics, Inc. University of Washington & Harborview Medical Center
Wilmington, No rth Carolina Director, Prosthetics Research Study
Medical Director, Amputee Coalition of America
John C. Racy, MD Seattle, Washington
Professor of Psychiatry
Department of Psychiatry Gerald E. Stark Jr, CP*
University of Arizona College of Medicine Director of Education and Technical Support
Tucson, Arizona The Fillauer Companies, Inc.
Chattanooga, Tennessee
Robert Radocy, MS*
President, CEO H . Thomas Temple, MD*
TRS, Inc. Professor of Orthopaedics and Pathology
Boulder, Colorado Division of Orthopaedic Oncology
Department of Orthopaedics and Rehabilitation
Zahid Raza, MD, FRCSEd, FRCS University of Miaini School of Medicine
Specialist Registrar in Vascular Surgery Miami, Florida
Department of Vascular Surgery
Royal Infirmary of Edinburgh Jose J. Terz, MD
Edinburgh, Scotland Clinical Professor of Surgery
Department of Oncologic Surgery
Kingsley Peter Robinson, MS, FRCS Uni ve rsity of Southern California
Consultant Advisor in Osseointegration Los Angeles, California
Queen Mary's Hospital
Roehampton, London, England Jack E. Uellendahl, CPO
Visiting Professor in Biomedical Engineering Hanger Prosthetics and Orthotics, Inc.
University of Surrey Phoenix, Arizona
Guildford, Surrey, England
Lawrence D. Wagman, MD
Rebekah Russ, CPO, LPO Chair, Division of Surgery
Department of Prosthetics and Orthotics City of Hope Cancer Center
Texas Scottish Rite Hospital for Children Duarte, California
Dallas, Texas
David A. Ward, FRCS Orth
Roy Sanders, MD Consultant Orthopaedic Surgeon
Chief, Department of Orthopaedics Kingston Hospital NHS Trust
Tampa General Hospital Kingston-Upon-Thames
Tampa, Florida Surrey, England
Shahan K. Sarrafian, MD Robert L. Waters, MD

Clinical Associate Professor, Emeritus Clinical Professor Orthopedic Surgery
Department of Orthopaedic Surgery University of Southern California
Northwestern University, Feinberg School of Medicine Department of Surgery
Ch icago, Illinois Rancho Los Amigos National Rehabilitation Center
Downey, California
Michael L. Schmitz, MD
Pediatric Orthopaedic Surgeon Hugh Watts, MD
Children's Orthopaedics of Atlanta Clinical Professor of Orthopedics
Children's Heal thcare of Atlanta at Scottish Rite University of California at Los Angeles
Atlanta, Georgia Shriners Hospital for Children, Los Angeles
Los Angeles, California
C. Michael Schuch, CPO
Vice President of Clinical Services Richard F. ff. Weir, PhD
Assistant Clinical Professor Research Healthcare Scientist
Center for O rthotic and Prosthetic Care Department of Veterans Affairs
Duke University Medical Center Northwestern University Prosthetics Research Laboratory
Du rham, North Carolina VA Chicago Healthcare System
Chicago, Illinois
Alexander Y. Shin, MD
Consultant, Hand Surgery Saeed Zahedi, OBE, FIMechE
Assistant Professor, Orthopedic Surgery Head of Technology
Department of Orthopedic Surgery PDD Group, Ltd.
Mayo Clinic London, England
Rochester, Minnesota
* Has received something of value from a commercial or other party related
directly or indirectly to the subject of his/her chapter.

ix
Foreword
Limb amputations and congenital limb deficiencies are as economic reward or, even worse, an unsupervised surgical
old as humanity. Amputation represents an irreversible opportunity for the beginn er. This widespread attitude re-
loss of physical integrity that is very often considered a sults in the selection of amputation levels that are much
form of punishment both for the patient and indirectly for too proximal, increasing the disability unnecessarily, and
the patient's family and society. In some cultures, an am- in the creation of residual limbs of poor quality. For these
putee is even believed to be denied Paradise. In medieval reasons, I wish I had been confronted more often with the
law, amputation was a common penalty, a sort of partial opportunity for primary amputations rather than surgical
execution, and is still practiced in certain countries. As re- revisions. Limb amputation is not to be considered a self-
cently as the year 2000, terrorist rebels in Sierra Leone, learning experience for unsupervised beginners, but rather
West Africa, cut off the hands of an estimated 10,000 civil- a challenge even for the experienced surgeon, whether a
ians. The need for limb replacement is, therefore, as old as general, oriliopaedic, pediatric, vascular, or plastic and re-
civilization itself. The earliest known prosthesis, a beauti- constructive surgeon. It is also true that the best results
fully designed hallux made some 4,000 years ago in Egypt, will usually be achieved by surgeons who have some basic
was probably not the first one ever made. knowledge of prosthetics and amputee rehabilitation.
Today, despite great progress in medicine and tech nol- As in any medical specialty, there are limits to surgery
ogy, the basic considerations with regard to amputation and to prosthetics that should be recognized. This is be-
and prosthetics remain constant. The disability increases cause amputation is far more than simply a surgical and
with each more proximal level of amputation, particularly prosthetic affair. In surgery, the limits are set by physiol-
with the loss of major joints. For example, tl1e bilateral ogy, bacteriology, immunology, and, last but not least, by
transfemoral amputee suffering from peripheral arterial ethical considerations. All these factors come to the fore,
occlusive disease will never be able to walk effectively to varying degrees, in any discussion of "future develop-
again, even with the most sophisticated prostheses. And ments" such as osseointegration and hand transplantation.
despite advances in electronically controlled prostheses, The question of whether there is a future for these contro-
bilateral short transhumeral amputees will always require versial procedures remains open. It seems logical that bac-
help for daily activities, such as personal hygiene, eating, teria would be grateful for the open door offered by os-
and writihg. For these amputees, technical aids for daily seointegration, although it works wonderfully in
living and professional activities-such as the devices de- maxillofacial surgery. The constraints imposed by Wolff's
veloped by Ernst Marquardt and Eberhard Franz i11 Law in regard to the mechanical strains to bone at the
Heidelberg, Germany, in 1976 that allow an armless per- implant-bone interface are also considerable. Because of
son to drive a car-become more important for rehabilita- tl1e multiplicity of tissue types involved in hand transplan-
tion than does any prosthetic replacement. With regard to tation, the future of this field remaim firmly tied to future
congenital deficiencies, surgeons should be particularly developments in the field of immunology. The question-
aware that, in most cases, it is better not to remove more able safety of long- term use of current forms of immuno-
than is already missing because even rudimentary limbs suppression as well as the psychological stress associated
can become highly functional in the hands of a knowl- with this entirely elective procedure require careful con-
edgeable, creative prosthetist. sideration. Nonetheless, the cautious and factual presenta-
Unfortunately, most surgeons who perform amputation of the latest information on these techniques in this
tions are not aware of tl1eir responsibility in selecting the text, including the current barriers to their success, serves
most distal possible amputation level and creating a resid- a very useful purpose in avoiding unrealistic expectations
ual limb that is free of pain and is fu nctional with or with- of their current applicabilit y on the part of both the med-
out a prosthesis. Some surgeons may consider amputation ical and lay communities. Whether the barriers remain in-
rather a n uisance-as an operation witl1 little social and surmountable remains to be seen.

x
In regard to the virtually total prosthetic replacement their respective fields who have made contributions in 79
of an upper limb, results of long-term follow-up of upper chapters, has been conducted by three internationally
limb amputees fitted with the most sophisticated electron- known experts. Most of the contributors also play an ac-
ically controlled, electrically powered arm prostheses are tive role in the highly respected International Society for
needed. In these cases, technical aids, although much less Prosthetics and Orthotics (ISPO).
spectacular, are usually far more important for a useful re- I would like to congratulate the editors and the contrib-
habilitation result. utors for the immense work they have accomplished. This
Above all, amputation is a challenge not only to the Atlas represents the state of the art, particularly in North
surgeon and the prosthetist, but to many other profession- America. Being an orthopaedic surgeon who has been fas-
als as well. For the best results in rehabilitation, the team cinated by amputation surgery, prosthetics, and rehabilita-
approach is of utmost importance, although coordination tion throughout a professional lifetime in Switzerland and
of effort is sometimes frustra tingly difficult to achieve. As in Germany, I am most interested to learn what is going on
in an orchestra, the various specialists must each play their elsewhere. I am particularly grateful to the editors for hav-
part at the appropriate time, with one person prepared to ing given me the chance to contribute a foreword to this
play the role of the conductor. In this third edition of the Atlas. Like its predecessors, this edition will be the manual
Atlas, the orchestra, consisting of specialists recognized in to be consulted the world over.
July 15, 2003
Rene F. Baumgartner, MD
Emeritus Professor of Orthopaedic Surgery
University of Muenster, Germany
Department of Prosthetics, Orthotics, Rehabilitation
and Related Surgery
Address:
Langwisstrasse 14
CH-8126 Zumikon, Switzerland
rabaumgart@bluewin.ch

xi
Preface
With the third edition of this Atlas, the American Academy consumer mo~ement, and the rapidly expanding role of
of Orthopaedic Surgeons (AAOS) continues a commit- sports and recreation for amputees, as well as the more
ment that began in 1960 with the publication of Volume 2 controversial topics of osseointegration and transplanta-
of The Orthopaedic Appliances Atlas: Artificial Limbs. Now, as tion. Contemporary European contributions to partial
then, the goal of the Academy is to provide its members foot amputation surgery have been included for the first
and all amputee rehabilitation team members with the lat- time. The major influence of orthopaedic surgeons on the
est knowledge relating to amputation surgery, congenital development of both ampilltation surgery and prosthetics
deficiencies, prosthetics, and rehabilitation. In that first is noted in the greatly expanded chapter on the history of
text, the emphasis was on prosthetics, perhaps in deference these fields. Several new pediatric issues are covered, in-
to Donald Slocum's highly regarded and encyclopedic Atlas cluding the psychological impact, not only on the child
of Amputations, which had appeared in 1949. The Ortho- but also on the family, of a congenital or acquired limb de-
paedic Appliances Atlas did, however, include brief sections ficiency. A chapter on absence of the lumbar spine and
on amputation surgery and rehabilitation, setting the pre- sacrum bas been added, as well as a chapter on surgical re-
cedent for the increasingly holistic approach of later edi- vision.
tions. A much greater emphasis on surgery was apparent in We hope that both the new and the expanded chapters
the first edition of the current series, The Atlas of Limb Pros- will enhance the book's usefulness to all members of the
thetics: Surgfcal and Prosthetic Principles, which appeared in amputee rehabilitation team, including surgeons (whether
1981. The second edition of 1992 featured, in addition to general, vascular, pediatric, plastic, or orthopaedic), physi-
advances in surgical technique and prosthetics, an in-depth atrists, prosthetists, physical and occupational therapists,
review of the latest physical and occupational therapy recreational therapists, bioengineers, rehabilitation nurses,
methods used in the prosthetic and nonprosthetic rehabil- social workers, and amputees and their families.
itation of amputees, an emphasis reflected in the book's The support of the Academy's Board of Directors has
subtitle, Surgical, Prosthetic, and Rehabilitation Principles. made this volume possible and is gratefully acknowledged.
In this latest edition, we have sought to present the ma- The work of the authors and editors has been greatly en-
jor advances of the past decade. A number of new authors hanced by the deft touch of the Academy's publication
have been recruited to provide additional chapters on am- staff, resulting in what we trust is a cohesive and readable
putee care in wartime, the role of the Krukenberg proce- text.
dure in developing countries, the rise of the amputee Douglas G. Smith, MD
John H. Bowker, MD

xiii
Table of Contents
Section I: Introduction
1 The History of Amputation Surgery and Prosthetics . . . . . . . . . . . . . . . . . . 3
John H. Bowker, MD
Charles H. Pritham, CPO
2 General Principles of Amputation Surgery . . . . . . . . . . . . . . . 21
3 Vascular Disease: Limb Salvage Versus Amputation . . . . . . . . . . . 31
Peter T. McCollum, MCh, FRCSI, FRCSEd
Zahid Raza, MD, FRCSEd, FRCS
4 Infection: Limb Salvage Versus Amputation . . . . . . . . . . . . . . . . . . . . . 47
John H . Bowker, MD
5 Tumor: Limb Salvage Versus Amputation . . . . . . . . . . . . . . . . . . . . . . 55
Walid Mnaymneh, MD
H . Thomas Temple, MD
6 Trauma: Limb Salvage Versus Amputation . . . . . . . . . . . . . . . . . . . . . . 69
Michael T. Archdeacon, MD
Roy Sanders, MD
7 Wartime Amputee Care. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 77
Section II: The Upper Limb

8 Kinesiology and Functional Characteristics of the Upper Limb. . . . . . . . . . . . . 101
Br,ian J. Hartigan, MD
Shahan K. Sarrafian, MD
9 Body-Powered Components . . . . . . . . . . . . . . . . . . . . . . . . . . . . 117
Charles M. Fryer, MS
Gerald E. Stark Jr, CP
10 Harnessing and Controls for Body-Powered Devices . . . . . . . . . . . . . . . . . 131
John W Michael, MEd, CPO
11 Components for Electric-Powered Systems . . . . . . . . . . . . . . . . . . 145
Craig W. Heckathorne, MSc
12 Control of Limb Prostheses . . . . . . . . . . . . . . . . . . . . . . . . 173
Richard F. ff. Weir, PhD
13 Partial Hand Amputation: Surgical Management . . 197
E. Anne Ouellette, MD, MBA
14 Partial Hand Amputation: Prosthetic Management . . 209
Chris Lake, CPO .

xiv
15 Wrist Disarticulation and Transradial Amputation: Surgical Management . . . . . 219

Patrick Owens, MD
16 Wrist Disarticulation and Transradial Amputation: Prosthetic Management . . . . . . 223
Carl D. Brenner, CPO
17 The Krukenberg Procedure . . . . . . . . . . . . . . . . . . . . . . 231
Pradip D. Poonekar, MD
18 Elbow Disarticulation and Transhumeral Amputation: Surgical Management . . . . . . 239
Patrick Owens, MD
19 Elbow Disarticulation and Transhumeral Amputation: Prosthetic Management . . 243
Wayne K. Daly, CPO, LPO
20 Amputations About the Shoulder: Surgical Management . . . 251
21 Amputations About the Shoulder: Prosthetic Management . . 263
John M. Miguelez, CP
Randall D. Alley, CP
22 Prosthetic Training. . . . . . . . . . . . . . . . . . . . .275
Diane J. Atkins, OTR
23 Brachia[ Plexus Injuries: Surgical and Prosthetic Management . . 285
Allen T. Bishop, MD
24 Aesthetic Prostheses . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 303
Thomas Passero, CP
Kim Doolan
25 Bilateral Upper Limb Prostheses . . . . . . . . . . . . . . . . . . . .. . .. . 311
Jack E. Uellendahl, CPO
26 Prosthetic Adaptations in Competitive Sports and Recreation . . . . . . . . . . . . . 327
Robert Radocy, MS
27 Future Developments: Hand Transplantation . . . . . . . . . . . . . . . . . . . .. 339
Christopher H. Allan, MD ·
28 New Developments in Upper Limb Prosthetics . . . . . . . . . . . . . . . . . . . 343
Hans Dietl, PhD ·
Section Ill: The Lower Limb

29 Normal Gait . . . . . . . . . . . . . .. . . . . . . . . . . . . . . . . . . 353
Jacquelin Perry, MD
30 Amputee Gait. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 367
JacqueJjn Perry, MD
31 Visual Analysis of Prosthetic Gait . . . . . . . . . . . . . . . . . . . . . . . . 385
Susan L. Kapp, CPO
32 Energy Expenditure of Walking in Individuals With Lower Limb Amputations . . . . . 395
Robert L. Waters, MD
Sara J. Mulroy, PhD, PT
33 Prosthetic Suspensions and Components . . . . . . . . . . . . . . . . . . . . . . 409

xv
34 Amputations and Disarticulations Within the Foot: Surgical Management . . . . . . . 429

John H. Bowker, MD
35 Amputations and Disarticulations Within the Foot: Prosthetic Management . 449
David N. Condie, CEng
Roy Bowers, SRProsOrth
36 Ankle Disarticulation and Variants: Surgical Management . . 459
John H. Bowker, MD
37 Ankle Disarticulation and Variants: Prosthetic Management . . . . . . . . . . . . . 473
Gary M. Berke, MS, CP
38 Surgical Management . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 481
John H. Bowker, MD
39 Transtibial Amputation: Prosthetic Management . . . . . . . . . . , . . . . . . . 503
Susan L. Kapp, CPO
John R. Fergason, CPO
40 Knee Disarticulation: Surgical Management . . 517
Michael S. Pinzur, MD
41 Knee Disarticulation: Prosthetic Management . . . . . . . . . . . . . . . . . . . 525
Donald R. Cummings, CP, LP
Rebekah Russ, CPO, LPO
42 Transfemoral Amputation: Surgical Management . . 533
Frank Gottschalk, MD, FRCSEd, FCS(SA)
43 Transfemoral Amputation: Prosthetic Management . . . . . . . . . . . . . . . . . 541
Charles H. Pr itharn, CPO
44 Hip Disarticulation and Transpelvic Amputation: Surgical Management . . 557
Howard A. Chansky, MD
45 Hip Disarticulation and Transpelvic Amputation: Prosthetic Management . . . . . . . 565
Kevin M. Carroll, MS, CP
46 Translumbar Amputation: Surgical Management . . . . . . . . . . . . . . . . . . 575
Jose J. Terz, MD
47 Translumbar Amputation: Prosthetic Management . . . . . . . . . . . . . . . . . 583
Greg Gruman, CP
48 Physical Therapy . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 589
Curtis R; Clark, PT
49 Bilateral Lower Limb Prostheses. . 621
Jack E. UeUendahl, CPO
50 Prostheses for Sports and Recreation . . . . . . . . . . . . . . . . . . . . . . . 633
David Alan Boone, CP, MPH
51 Physical Therapy for Sports and Recreation . . . . . . . . . . . . . . . . . . . . 641
52 Research in Lower Limb Prosthetics . 661
Saeed Zahedi, OBE, FIMechE

xvi
Section IV: Management Issues

53 Future Developments: Osseointegration in Transfemoral Amputees. . . . . . . . . . .673
Kingsley Peter Robinson, MS, FRCS
Rickard Branemark, MD, MSc, PhD
54 Musculoskeletal Complications . . . . . . . . . . . . . . . . . . . 683
John J. Murnaghan, MD, MSc, MA, FRCSC
John H. Bowker, MD
SS Skin Problems in the Amputee. . . . . . . . . . . . . . . . . . . . . . . .701
S. Willian1 Levy, MD
56 Chronic Pain Management . . . . . . . . . . . . . . . . . . . . 711
Dawn M. Ehde, PhD
57 Psychological Adaptation to Amputation . . . . . . . . . . . . . . . . . . . . . 727
John C. Racy, MD
58 The Art of Prosthesis Prescription . . . . . . . . . . . . . . . . . . . . . . . . 739
John H. Bowker, MD
59 Rehabilitation Without Prostheses . . . . . . . 745
Joan E. Edelstein, MA, PT
60 Special Considerations: Consumer Movement. .757
Mary P. Novotny, RN, MS
Section V: Pediatrics
61 The Limb-Deficient Child . . . . . . . . . . . . . . . . . . . . . . . . . . . . 773
John R. Fisk, MD
62 Terminology in Pediatric Limb Deficiency . . . . . . . . . . . . . . . . . . . . . 779
John R. Fisk, MD
63 . Developmental Kinesiology . . . . . . . . . . . . . . . . . . . . . . . . . . . 783
64 General Prosthetic Considerations . . 789
65 Psychological ls~ues in Pediatric Limb Deficiency . . . . . . . . . . . . . . . . . . 801
Alice L. Kahle, PhD
66 Occupational Therapy . . . . . . . . . . . . . . . . . . . . . . . . . . 813
Joanna G. Patton, OTR/L
67 Physical Therapy . . . . . . . . . . . . . . . . . . . . . . . . . . . . 831
Colleen Cou lter-O'Berry, PT, MS, PCS
68 Acquired Amputations in Children . . . . . . . . . . . . . . . . . . . . . . . . 841
John P. Dormans, MD
Biilent Erol, MD
Christopher B. Nelson, CPO
69 Hand Deficiencies . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 853
Terry R. Light, MD
70 Radial Deficiencies. . . . . . . . . . . . . . . . . . . .863
Terry R. Light, MD
)-
American Acl:lemy of Orthopaedic Surgeons

xvii
71 Longitudinal UJ.nar Deficiency . . . . . . . . . . . . . . . . . . . . . . . . . . 869

Julian E. Kuz, MD
James Engels, MD
Humeral Deficiencies. . . . . . . . . . . . . . . . . . . . . . . . . . . . . 875
72
Mary Williams Clark, MD
Chris Lake, CPO
73 Foot Deficiencies . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 885
Mary Wi lliams Clark, MD
74 Fibular Deficiencies . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 889
Gerard L. Glancy, MD
75 Tibial Deficiencies . . ............ . 897
Michael L. Schmitz, MD
Brian J. Giavedoni, MBA, CP
, Colleen Coulter-O'Berry, PT, MS, PCS
76 Femoral Deficiencies . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 905
Kenneth J. Guidera, MD
Cara D. Novick, MD
Janet G. Marshall, CPO
77 Absence of the Lumbar Spine and Sacrum. . . . . . . . . . . . . . . . . . . . . 917
James T. Guille, MD
S. Jay Kumar, MD
78 Multiple Limb Deficiencies . . . . . . . . . . . . . . . . . . . . . . . . . . . 923
Hugh Watts, MD
79 Surgical Modification of Residual Limbs . . . . . . . . . . . . . . . . . . . . . 931
Hugh Watts, MD II
Appendix: Terminology in Acquired Limb Loss . . . . . . . . . . . . . . . . . . . 945

John H . Bowker, MD
Index . . . . . . . . . . . . . . . . . . . . .. . . . . . . . . . . . 947
Index of Manufacturers . . . . . . . . . . . . . .. . . . . . . .. . . . . . .965

;r'I"!~ Introduction
The History ofAmputation
Surgery and Prosthetics
John H. Bowker, MD
Introduction
T he distinct but interdependent fields History of Celsus (25 BCE to 50 CE) . While still re-
of amputation surgery and prosthet- stricting amputation to cases of gan-
Amputation Surgery grene, he recommended transosseous
ics have historical roots extending
back to about 1800 BCE when, accord-
Expansion of Indications division at the junction of viable and
ing to the Rig-Veda, the Indian for Amputation gangrenous tissue. He also advocated
warrior-Queen Vishpla bad her leg Early surgeons were strongly influ- vessel ligation, invented earlier by Al-
amputated folJowing a battle, was fit- enced by the writing of Hippocrates exandrian surgeons, as well as wound
ted with a prosthesis made of iron, (460 to 377 BCE), the greatest medical compression for hemostasis. Both
techniques made surgery considerably
and subsequently returned to lead her authority of antiquity. He considered
safer. Celsus considered cauterization
troops. The oldest archeologic evi- gangrene the only indication for am-
of vessels by hot irons as the last re-
dence of amputation dates to 45,000 putation and recommended cutting
sort. Over the next half century, indi-
years ago. Study of a male Neander- through insensate necrotic tissue,
cations were expanded much further
thal skeleton, found in present day preferably the knee joint, analogous
by Archigenes and Heliodorus to in-
Iraq, indicated that he had survived to to a debridement rather than a defin-
clude chronic leg ulcers, tumors,
age 40 years with an atrophic right itive procedure. Any attendant bleed-
trauma, and congenital malforma-
upper limb that had been amputated ing was controlled by cauterization.
tions. This extension of indications to
just above the elbow. The oldest sur- Battle wounds were, of course, an-
include even semielective problems
viving prosthesis (roughly 1000 BCE) is other matter. Hippocrates wisely ob-
was made possible by the use of a
an artistically carved wooden hallux served that "war is the only proper tight bandage proximal to the site of
found on a female mummy in the school for the surgeon." This was true the amputation. Larger vessels were
west Theban Necropolis. It is held in because of the battle surgeon's intense controlled with ligatures and smaller
place by a laced leather band around exposure to wide varieties of injuries ones with compression and torsion.
the forefoot and shows signs of wear inflicted by the assorted cutting, Additiional indications mentioned in
from use. piercing, and crushing weapons then the Talmud were leprosy and other
To present the many changes that in use. Although surgeons of that incurable infections. Thereafter,
have occurred in these two fields over time could do little for soldiers with through the influence of the plentiful
time, we will separately examine the severe wounds of the trunk or head, writings of the Roman physician Ga-
evolution of those individual aspects they frequently encountered combat- len (131 to 201 C£), there was a return
of prime interest to the amputation ants with limb injuries whose lives to the teachings of Hippocrates, in-
surgeon, prosthetist, therapist, and could, at times, be saved by amputa- cluding amputating only through ne-
other members of the rehabilitation tion. Judicial amputation of crimi- crotic tissue or the knee joint, al-
team. The political, social, and eco- nals' hands was also widely practiced, though Galen did use ligatures for
nomic forces that influenced both sanctioned by both the Babylonian hemostasis.
advances and regression are men- Code of Hammurabi and the Mosaic Fofilowing the decline of Roman
tioned where appropriate. We begin law. influence during the third and fourth
with the development of amputation The next reference to surgical .indi- centuries C£, Roman advances in
surgery. cation was by the Roman physician medicine made before those of Galen
American Academy of Orthopaedic Surgeons 3

4 Section I: Introduction
saders (11 th to 13th centUl'ies), is tures for hemostasis, rather than cau-
characterized by loss of limb sensa- terization with hot irons-two ideas
tion. Repetitive trauma frequently re- lost for a millennium. He also aban-
sults in painless injury to the hands doned the use of boiling oil for cau-
and feet, leading to ulceration and terization of wounds contaminated by
deep infection. Ergot poisoning fol- gunpowder, which was thought to be
lows ingestion of bread made from poisonous, after he fortuitously ran
rye flour contaminated with an alka- out of oil during a battle. The imme-
loid produced by the fung us Claviceps diate improvement in his results rein-
purpurea. In 857, the first of many Eu- forced his resolve to abandon this ex-
ropean pandemics occurred among cruciatingly painful measure. Pa.re's
the poor, for whom rye bread was a other great contribution was making
staple food. Ergotism is manifested by Vesalius' monumental anatomic trea-
the painful burning sensation of pro- tise De Fabrica Humani Corporis Libri
longed arterial vasoconstriction, Septem (1543) readily accessible to his
hence the names ignis sacer (sacred contemporaries by publishing an
fire) or St. Anthony's fire (Figure l). epitome in vernacular French.
Autoamputation or surgical ablation The Napoleonic Era (1792 to 1815)
of gangrenous hands and feet was produced two great military surgeons:
Figure 1 St. Anthony, patron saint of er- usually followed by recovery, while George Guthrie on the British side
gotism, is shown with a victim of the dis-
vasoconstriction of mesenteric arter- and Dominique-Jean Larrey on the
ease. The flames emanating from the vic-
tim's left hand symbolize the burning ies was rapidly fatal. Although far French. Larrey concurred with Guth-
pain of severe vasoconstriction caused by from a new indication, amputations rie that prompt primary amputation
ergotism, or "St. Anthony's fire." He uses from battle wounds greatly increased on the battlefield resulted in fewer fa-
a kneewalker peg-leg because of the loss in number following the introduction talities than waiting the commonly
of his right foot. (Reproduced from Hans
of the cannon at the Battle of Crecy in recommended 3 weeks before second-
von Gersdorff: Field-Book of Wound Sur-
gery. Strassberg, 1540.) 1346 and of muskets at Perugia in ary amputation. To permit rapid ac-
1364. The wounds incurred were so cess to injured solders, Larrey intro-
severe, compared to those from cut- duced "flying ambulances" to pick up
did not pass into the succeeding Byz- ting or piercing weapons, that sur- the wounded during battle and trans-
antine and Arabic medical traditions. geons became newly interested in am- port them to an aid station (Figure 2).
Instead, with the rise oflslam, the nu- putations as a worthy endeavor. Using this method, Larrey was able to
merous works of Hippocrates and During the Renaissance (14th to provide truly expeditious care for the
Galen were translated from Greek 16th centuries), the original works of men of Napoleon's Imperial Guard.
into Arabic by Persian scholars in the Hippocrates, Galen, and, most signifi- During one battle, only 43 of 12,000
seventh and eighth centuries. This cantly, Celsus were rediscovered in casualties brought to his aid station
perpetuated their influence for the cloister libraries and widely circulated died, a record far better than that of
next thousand years, aided by belief with the aid of the printing press. other French army units.
in their infallibility on the part of Prior to this, European physicians had During the American Civil War
both Muslims and Christians. Other only Latin translations of Arabic (1861 to 1865), the severity of limb
influences maintaining the status quo translations made from the original wounds increased markedly with the
were the conservatism of the Chris- Greek, with many attendant inaccura- introduction of the French minie ball,
tian church regarding anatomic stud- cies. With the rise of Humanism and a conical bullet with a hollow base
ies, a prohibition against surgery, and a relative decline in ecclesiastical au- that expanded as it left the rifle barrel,
the feuding of rival medical groups. thority, DaVinci ( 1452 to 1519) was splintering bone on impact. The ex-
These factors led to widespread disable to undertake detailed anatomic tensive damage to both soft and bony
crimination against surgery and its studies that refuted some of Galen's tissue led to a refinement of indica-
practitioners, who were held in low revered notions. Unfortunately, Da- tions for primary amputation . These
esteem. Vinci's work was suppressed for an- included, in both the Union and the
Nonetheless, in Europe during the other century. Confederate Armies, comminuted
Middle Ages (s::irca 476 to 1453 CE), Ambroise Pare (1509 to 1590) con- open fractures, open joints with frac-
indications for amputation continued tributed greatly to the development of ture, major nerve or blood vessel in-
to expand and now included limbs modern amputation surgery during jury, extensive soft-tissue injury, and
damaged by leprosy and ergotism. this period by reintroducing Celsus' crush. The modern introduction of
Leprosy, a mycobacterial infection in- principles, namely, amputation blood replacement, aseptic surgery,
trod uced to Europe by returning Cru- through viable tissue and using liga- antibiotics, primary vascular repair,

Chapter 1: The History of Amputation Surgery and Prosthetics 5
and external skeletal fixation, aug-

mented by helicopter evacuation to
well-equipped forward hospitals, has
since narrowed this list of absolute in-
dications for amputation while ex-
panding the indications for attempts
at limb salvage. Nonetheless, the list
remains basically valid in many less
than ideal circumstances.
Advances in Level Selection

As mentioned above, Hippocrates
recommended amputation through
gangrenous tissue, thereby averting
much of the pain of surgery as well as
reducing the likelihood of exsan-
guination. Celsus' use of ligatures for
hemostasis allowed him to amputate
through viable tissue, but this tech-
nique was lost for a millennium after
the fall of Rome. Hieronymus Brun-
schwig (1425 to 1520) recommended
amputation below the knee whenever
possible and considered knee disartic- Figure 2 Ambulance volante (flying ambulance) invented by Larrey to rap idly collect
wounded men during a battle fo r t ransfer to an aid station. (Reproduced from van der
ula tion the most proximal level con-
Mei} WKN: No Leg to Stand On. Groningen, AE Brinkman, 1995, p 84.)
sistent with survival. Within a half
century, however, Pares reintroduc-
tion of the ligature allowed him to re- the kneewalker peg-leg then in use. 1f calcaneal fragment to the distal tibia,
port the first successful transfemoral only a very short level could be sal- allowing the use of standard work
amputation. The English surgeon vaged, Larrey advocated removing the boots. In 1939, the American ortho-
James Kerr, in 1774, was the first to fibula entirely. paedist Harold Boyd reported a simi-
report survival of a patient following A number of end- weight-bearing lar procedure. Despite the develop-
hip disarticulation for 18 days, at ablations were developed about this ment of these new distal techniques,
which point she succumbed to tuber- time that either eliminated the need the transfemoral level remained dom-
culosis. During the Napoleonic wars, for a prosthesis entirely or permitted inant throughout World War I. In
Larrey, and later Guthrie, performed fitting of a simplified, less expensive 1914, Blake reported that 70% of am-
successful hip disarticulations on the one. These were important develop- putations were at that level, while J.S.
battlefield. A consummate anatomist, Speed's series was 58.6% transfemo-
ments because the transtibial ampu-
Larrey was able to complete the open ral. Overall, of the total 42,400 lower
tee who could not afford a prosthesis
disarticulation within 15 seconds of
that permitted knee motion was rele- limb amputations sustained by the
ligating the femoral vessels. It should
gated to a kneewalker peg-leg. The Allied Forces, 39.6% were transfemo-
be noted that, prior to the discovery
first of these procedw·es was the mid- ral. The first successful transpelvic
of effective anesthetic agents, the
tarsal disarticulation described by amputation was carrie~ out by the
most sought-after surgeons combined
Francois Chopart in 1792, followed French smgeon Mathieu Jaboulay in
a profound knowledge of anatomy
closely by Jacques Lisfranc's tar- 1894. In1mediately following World
with dexterity and speed to shorten
sometatarsal disarticulation in 1815 War II, basic research into normal hu-
the patient's period of extreme pain .
Fortunately, this is no longer neces- and James Syme's ankle disarticula- man gait, under United States Federal
sary, and more attention now can be tion in 1843. Nikolai Pirogoff, a Rus- government sponsorship, was begun
focused on reconstruction of a resid- sian surgeon who admired Syme's in- by Verne Inman and Howard Eber-
ual limb that will interface comfort- novation, found that he was unable to hart at the University of California at
ably with a modern prosthesis. As to provide Russian peasant-soldiers with Berkeley. Their studies demonstrated
the preferred length for a transtibial a prosthesis that would control an un- that amputees' gait would benefit by
amputation, both Larrey and Guthrie stable heel pad following that proce- retention of as much healthy bone
opted for a short transtibial limb of dure. Therefore, in 1854, he stabilized and soft tissue as possible. This con-
8 to 10 cm to more conveniently fit the heel pad by fusion of an attached clusion was in sharp contrast to the

allowed the skin to be drawn distally

to cover the end of the bone. With tl1e
decline of Rome, this advancement
was lost,. only to be rediscovered dur-
ing the Renaissance. A number of new
techniques based on Celsus' principle
appeared in the 18th centmy. During
·1717 and 1718, the contemporaries
Jean Louis Petit, Lorenz Heister, and
William Cheselden favored making a
circular incision through skin and fat,
pulling these tissues proximally, then
dividing the muscle and bone. Ed-
ward Alanson ( 1779) created a less
bulky residuum by following the skin
and fat incision with an oblique cut
through muscle from distal to proxi-
mal, followed by division of the bone
at the apex of the muscle cone.
The triple circular incision was in-
troduced by Henri-Francois LeDran
(1731) and Benjamin Bell (1787). Fol-
lowing succeeding circular divisions
Figure 3 The transtibial amputation of Verduyn (1696) showing his posterior myofascio-
cutaneous flap. A, The flap. B, The completed residual limb. He also designed a prosthe- of the skin and subcutaneous tissue
sis with a movable knee specifically to permit the full benefit of this advanced surgical and a muscle layer, both were pulled
technique. (Reproduced from Heister L: Chirurgie. Nuremberg, 1718.) proximally to the level of bone divi-
sion. This was the method used by
both Dominique-Jean Larrey and
time-honored practice of amputating the muscle contracts, it pulls on the
George Guthrie during the Napole-
at fixed sites in each limb segment as cable activating the hand. In 1916,
onic Wars. Although double and tri-
agreed on by surgeons and prosthe- Sauerbruch and ten Horn refined the
ple circular incisions remained the
tists. procedure by lining the tunnel with a
most common methods used to en-
Turning to the upper limb, Pare medially based skin flap. Thereafter, it sure that bone remained well covered,
performed the first elbow disarticula- was used during both world wars, but other surgeons were developing flaps
tion in 1536; Henri-Francois LeDran, with the widespread availability of for wound closw·e, beginning in 1679
the first successful shoulder disarticu- myoelectric prostheses, it is now with James Yonge, a British naval sur-
lation in 1731; and John Cuming, a rarely used even though some re- geon. Shortly thereafter, in 1696, Pi-
British naval surgeon, is credited with searchers believe that this surgery eter Verduyn described the first long
the first successful forequarter ampu- may prove useful in the futw·e to con- posterior myofasciocutaneous flap for
tation. The concept of cineplasty as a trol prosthetic hands with multifunc- transtibial amputation (Figure 3). H.
means to capture the pbwer of arm tional fingers. Ravaton (1739) and Vermale (1756)
and forearm muscles to control a reported the first use of sagittal flaps
prosthetic hand was developed in Evolving Techniques for
consisting of skin and muscle. In ad-
chickens by the Italian Giuliano Vang- Bone Coverage dition, the French surgeon Raphael
hetti in 1896. His associate A. Ceci From the time of Hippocrates until Bienvenu Sabatier in 1796 described a
first applied it to Italian soldiers the first century, the recommended myofasciocutaneous flap raised from
whose hands had been amputated technique for limb amputation was ilie anterior leg to close a knee disar-
while war prisoners of the Ethiopians. division of all tissues at the same ticulation. In 1915, during World War
The following briefly describes the level. As these open wounds healed by l, Fitzmaurice-Kelly performed emer-
steps in cineplasty. First, a transverse secondary intention, the soft tissues gent flapless open amputations at the
tunnel is mad~ in a muscle, then its contracted, resulting in a conical re- most distal level of viable tissue to
insertion is severed. After healing has sidual limb with the bone prominent save limb length. He considered this
occurred while keeping the tunnel distally. Early in the first century, the first stage of a two-stage proce-
patent, a rod is passed through the however, Celsus advocated cutting the dure, using skin traction in the in-
tunnel and harnessed to a cable at- bone at a higher level than the soft terim. The American surgeon Kellogg
tached to the prosthetic hand. When tissues. This double circular incision Speed modified this technique by in-

cising the skin longitudinally on each indication with the transection to be

side in preparation for the secondary done through necrotic tissue to de-
closure. UsiJ1g this method, he found crease the chance of fatal hemor-
that the wounded could be moved rhage. In addition, because hemor-
safely to a rear hospital 1 week after rhage was more easily controlled by
amputation. cauterization or bandaging at distal
Although these incremental im- levels, only transtibial amputation or,
provements in technique tended to at most, knee disarticulation was rec-
produce marginally better residual ommended.
limbs, the bone would often become It remained largely for military
prominent over time as soft-tissue at- surgeons to gradually improve the
rophy occurred, leading to distal dis- outlook for survival by controlling
comfort and ulceration with use of a blood loss during amputation. The
prosthesis. This was noted to be espe- evolution of intraoperative hemosta-
cially common following transfemo- sis evolved over many centuries,
ral amputation if the muscles were beginning with the introduction of
not attached stably over the end of ligatures by Celsus, and their reintro-
the femm. After World War II, the duction by Pare during the Renais-
sance. A precursor of tourniquets was
myoplasty methods of the German
a circular bandage placed proximal to
Stugeons F. Mondry and R. Dederich,
the site of amputation, used by Archi- .
in which the d istal femur is covered
genes and Heliodorus in tl1e first cen- t
by suturing opposing muscles over its
tury. The French army surgeon Eti-
end, were widely adopted. In 1960,
enne Morel, however, introduced the
the Polish surgeon Marian Weiss in-
fust true tow-niquet, tightened by a
troduced myodesis, in which the mus-
stick, in 1674. Because tl1e stick often
cles are reattached to bone or perios-
obstructed the surgical site, it was Figure 4 The screw tourniquet, invented
teum to restore some of their motor
quickly displaced by Petit's screw by Petit in the early 18th century, was a
function. This concept was carried
tourniquet (roughly 1700) (Figure 4). great improvement on Morel's windlass
further by Frank Gottschalk, who in tourniquet because of its security. (Repro-
Nonetheless, mortality rates following
1990 demonstrated the value of pre- battle wounds remained so high t hat duced from Heister L: Chirurgie. Nurem-
serving the adductor power of a berg, 1718.)
Louis XIV (1638 to 1715) complained
transfemoral residuum by myodesing that "For my soldiers, the amputation
the adductor magnus tendon to the knife of my surgeons is fru· more dan-
lateral femoral cortex. Ample padding gerous [than] the enemie's [sic] fire." edly decreased intraoperative death
is then provided by suturing the It was eventually accepted that rates as well as deatl1 from wound in-
quadriceps muscle over the distal fe- mortality following amputations for fection and secondary hemorrhage.
mur. Distal coverage of a transtibial battle wounds was closely linked to Guthrie's experience with British ca-
residual limb with a posterior myo- the interval between wounding and sualties was sun ilar. During the
fasciocutaneous flap, introduced by surgery. Initially, opinion was sharply Crimean War (1853 to 1856), primary
Verduyn in 1696, was first used in the divided between those who advocated amputation resulted in a 37% mortal-
United States by William Bickel in primary amputation on the battlefield ity rate, compared to 60% for second-
1943 and later was widely promoted and those who would wait 2 to 3 ary ablation. The Union Army had a
by Ernest Burgess. weeks until it was clear that the pa- sunilar experience with 20,500 ampu-
tient was able to survive this initial tations during the American Civil
Mortality Related to period without surgical intervention. War, with a mortality rate of 35.7%.
Amputation By delaying treatment, these latter This was a marked improvement
From the eru·liest records, it is clear surgeons were able to claim a lower from the battle of Fountenoy in 1745,
that amputation commonly resulted rate of surgical mortality because when the mortality rate from ampu-
in death from blood loss during sur- most of the wounded had died of sep- tation was 90%.
gery or some days later from septice- sis or hemorrhage while waiting the The other major cause of death
mia, which was often associated with prescribed interval. Larrey's use of followiing amputation was septicemia.
secondary hemorrhage. These known "flyu1g ambulances" during the Napo- Although Hippocrates had recom-
risks led to the conservatism of leonic Wars to bring the wounded di- mended that sw-geons clean their
Hippocrates and his adherents who rectly to a surgical station dw-ing the hands and nails and use boiled water
accepted gangrene as the only proper battle for primary amputation mark- for wound cleansing, this advice was

achieved an overall amputation sur-

vival rate of 85%, using a combina-
tion of extensive wound debridement,
early open amputation, and wound
irrigation with Carrel-Dakin solution.
The availability of sulfonamides from
the beginning of World War II and
the introduction of penicillin in 1943
marked the beginning of the antibi-
otic era.
Surgical Analgesia and

Anesthesia
In the fourth century, Dioskorides, a
military surgeon under Nero, com-
piled the first Materia Medica, de-
scribing the medical uses of more
than 600 plants, including the anes-
thetic effects of mandrngora and
opium for surgical procedures. The
Talmud later mentions the specific
use of anesthesia for amputation as
Figure 5 Typical 18th century transtibial amputation, performed swiftly without anes- well. During the Middle Ages, the
thesia. The assistant on the right compressed the thigh to control hemorrhage. All tis- Spongia Soporifica, invented by Ugo
sues were divided at the same level, commonly resulting in a residual limb of poor qual- di Borgognoni of the University of
ity. (Reproduced from Heister L: Chirurgie. Nuremberg, 1718.)
Bologna, was widely used for surgical
anesthesia. A sponge was soaked in a
rarely heeded, either on the battlefield spraying of wounds with a carbolic mixture con taining, among other in-
or even in hospitals. Early attempts at acid solution. By using antisepsis, gredients, opium, mandragora, hyos-
wound lavage with puxported anti- Lister was able to reduce his 48% sur- cya111us, and hemlock, providing both
septics included the use of wine by gical mortality rate for amputations narcotic and atrophine-like effects
Avicenna in the Middle Ages and tur- performed from 1864 to 1866 to 15% when inhaled or swallowed. When
pentine by Pare during the Renais- for amputations performed from dried after preparation, the sponge
sance. The concept of asepsis pro- 1867 to 1870. Antisepsis opened a became easily portable, being recon-
gressed with Ignaz Semmelweis' 1848 new era of safety fo r elective surgery stituted with water when needed. For
report of the reduction in puerperal as well. By 1877, it was widely ac- the next four centuries, however, from
sepsis mortality from nearly 10% to cepted by most, including American the end of the Middle Ages (roughly
1.3% by enforced hand washing in a military surgeons. Antisepsis still re- 1450) until the mid 19th century, am-
solution of calcimn chl-0ride for all tains applicability for lavage of con- putations were done without benefit
personnel before any patient contact. taminated wounds as exemplified by of analgesia, placing a premium on
In 1865, Joseph Lister, appalled by the continued use of Carrel-Dakin so- the speed of the surgeon to lessen the
the high mortality rate from septice- lution (dilute sodium hypochlorite) duration of suffering. Because of
mia associated with open fractures and its various successors. these circumstances, little thought
and thoroughly familiar with the The progression from antisepsis to was given to the quality of the result-
work of Louis Pasteur, began treating asepsis was also based on the work of ing residual limb (Figure 5) .
fracture wounds with carbolic acid Pasteur. Ernst Von Bergmann, a The evolution of modern anesthe-
dressings in an attempt to sterilize prominent surgeon of the Franco- sia began with two notable events:
them, rather than doing primary Prussian war (1870 to 1871), intro- Hlunphrey Davey's description of the
amputations as commonly recom- duced steam sterilization of surgical pain-killing property of nitrous oxide
mended. Following successful salvage instruments in 1886. Then, in 1891, in 1792, and Michael Faraday's dem-
of several limbs by this method, he he began the gradual introduction of onstration of a similar effect from ni-
applied the principle of antisepsis to asepsis as we know it today, including trous ether inhalation in 1818. The
his surgical cases. This included pre- sterile gowns and gloves and the use first amputation using ether anesthe-
operative washing of hands and in- of masks. During World Wai· I, Brit- sia was transfemoral, done for tuber-
struments, as well as intraoperative ish, French, and American surgeons culosis of the knee by John Collins

Warren at the Massachusetts General France gradually led the way out of medicine." Richelieu, the Prime Min-
Hospital in Boston in 1846. Six weeks this morass during the 13th to 18th ister of Louis XIII, helped raise the
later, having heard of Warren's suc- centuries. The first attempts to legiti- standards and social st9 tus of army
cess, Robert Liston performed the mize smgery and to raise the status of smgeons by making them members
first amputation using ether anesthe- surgeons occurred circa 1250 through of the College of St. Cosmas. Surgical
sia in Britain at the University College the political influence of Jean Pitard, education, at least in France, was fi-
of London Hospital. Although he ac- the personal barber-surgeon to the nally brought to the same academic
complished this transfemoral ablation King. With royal support, Pitard level as university medicine in the
with his usual dispatch, the necessity founded a surgeon's guild called the mid 1700s with the founding of the
for extreme speed was over, to be suc- College of St. Cosmas. To ensure that Royal Academy of Surgery by Mare-
ceeded by a new luxury, the availabil- new applicants to the college had schal, the personal surgeon of Louis
ity of sufficient time to carefully exe- reached an acceptable level of knowl- XIV. In England, tl1e development of
cute a deliberate surgical plan and edge and experience, Pitard organized surgery lagged behind that of France,
deal with unexpected findings with- a 4-year apprenticeship that encom- but surgeons -and barbers finally be-
out the sometimes violent struggles of passed not only practical surgery but came differentiated, culminating in
a patient in extreme pain. The use of theoretical lessons, given for the first the 1800 fo unding of the Royal Col-
ether anesthesia was quickly adopted time in the French language. After lege of Smgeons of London and later
in 1847 by both Syme in Edinburgh passing an examination, the appren- the Royal College of Surgeons of En-
tices were called "master surgeons" gland.
and Pirogoff in Russia. Chloroform
was widely used by military surgeons and entitled to enter the college, open From the earliest times, military
an office, and train their own appren- surgeons learned the art of amputa-
during the American Civil War as a
tices. Despite these advances, how- tion surgery while treating wounded
safer alternative to ether under battle-
ever, real progress was stymied combatants. In fact, the first two illus-
field conditions.
throughout much of the Middle Ages trated books that discussed amputa-
Education and Training in because of the rivalries among the tion were written by experienced mil-
university medicine faculties, the
Amputation Surgery itary surgeons from Strassberg. The
master-smgeons' guild, and the bar- first was The Book of Wound Surgery
From ancient times, the place of sur- ber surgeons, characterized by con-
gery and surgeons in society has been by Brunschwig in 1497, followed by
stant bickering and ever-shifting alli- Hans von Gersdorff's Field-Book of
dictated by forces that directly or in- ances as each group sought to control
directly affected its advances and de- Wound Surgery in 1517, which con-
the others. The result of this divisive tained the first illustration of an am-
clines. In Rome, the role of physicians turmoil was a delay in the application
seems to have included surgery, espe- putation (Figure 6). Both of these
of new knowledge such as Servetus' books dealt with wounds caused by
cially by those with military experi- discovery (circa 1550) of the pulmo-
ence. During the Middle Ages, Ali Ibo firearms. Many other books dealing
nary (lesser) circulation and William
Sina, or Avicenna (980 to 1037 CE), with amputations followed. One by
Harvey's discovery (1628) of the sys- Pare was the first to provide designs
the leading Islamic medical scholar of temic (greater) circulation, advances
for a "wooden leg for the poor." In
his era, put forth two doctrines that, characteristic of the rise of scientific
1815, Guthrie published an epoch-
through the influence of Latin trans- medicine.
making treatise, Gunshot Wounds of
lations of his voluminous writings, A few foresighted physicians, how-
the Extremities Requiring Amputation,
became institutionalized by both the ever, who found their theoretical edu-
which enjoyed six editions. Formal
Christian church and the universities. cation useless for rendering aid on the
education in amputation surgery on a
The first tenet was that methodical battlefield, went to the best-regarded
sustained basis did not materialize
and logical reasoning (ratiocination) barber-surgeons for further training.
until after World War II, but interest
was superior, in medical treatment, to On becoming physician-surgeons,
in this topic has been waning in re-
first-hand experience and investiga- they retmned to the universities
cent years among surgeons in general.
tion. The second was that surgery, as a to teach surgery. Three physician-
hands-on profession, was an inher- surgeons of the period, Henri de
ently inferior and separate branch of Mondeville, Guy de Chauliac, and History of
medicine. Thus, university medical Lanfranc, wrote surgical texts. Lan-
Prosthetics
education in the Middle Ages became franc, the founder of smgery in
purely theoretical, leaving practical France, sought to bring the opposing Whether a result of conflict, accident,
treatment of illness and injury to camps together, teaching that "no one disease, or judicial decree, amputa-
nonacademically trained "popular can be a good physician who has. no tions have always been a part of hu-
physicians," barbers, smgeons, bath- idea of surgical operations, and that a man experience, as has been the de-
stove attendants, and assorted quacks. surgeon is nothing if ignorant of sire to replace the lost part for

Figure 8 A Gallo-Roman mosaic depict-

ing a hunter w ith a t ranstibial peg-leg.
(Courtesy of Professor R. Baumgartner,
MD, Zumikon/ZOrich, Switzerland.)
Figure 6 "Serratura" (sawing off)-the

f irst known illustration of amputation for the poor private soldier and a so-
surgery. Note the hemorrhage despite phisticated transfemoral prosthesis
th e tight bandages above and below the Figure 7 Cosmetic wooden hallux pros- resembling armor for wealthy officers,
incision. The scalpel lies in the fore- thesis found on female mummy circa
ground. The person behind wears t he Tau
as well as cleverly crafted prosthetic
1000 see. Note laced leather band around hands with locking fingers. Although
cross of St. Anthony, indicating that he forefoot. (Reproduced with permission
may have lost the fingers of his left hand from Nerlich A, Zink A: Eine Zehenproth-
peg-legs had been known since an-
from ergotism. (Reproduced from Hans ese an einer a/taegyptischen Mumie. Med cient times, Pare's design featured ele-
von Gersdorff: Field-Book of Wound Sur- Orth Tech 2002;122:32-33.) vated sides with straps to securely at-
gery. Strassberg, 757 7.)
tach the prosthesis to the thigh
(Figure 11). His endoskeletal trans-
from enemies. These included the
functional, cosmetic, or protective femoral prosthesis featured a leather
iron hands of the Roman Marcus
reasons or some combination of socket, a foot with a spring-loaded
Sergius and that of the Teutonic
these. The word prosthesis (plural midfoot hinge, ai,d a knee that could
knight Goetz von Berlichingen, which
prostheses), the proper name for an be unlocked for sitting. The whole de-
were designed to firmly lock onto a
artificial limb, derives from the Greek sword or shield in battle (Figure 9). vice was covered with thin iron plates
roots meaning "to place an addition," Despite the awakening of intellec- shaped to match the contours of the
whereas prosthetics is the professional tual curiosity in the Renaissance ( 14th opposite limb and was suspended
field that deals with the construction to 16th centuries), the development from an undervest (Figure 12). The
and custom-fitting of prostheses. of prosthetics during its first 200 most significant prosthetic design of
years did not keep pace with that of the Renaissance, however, was the
Evolution of Prosthetic transtibial prosthesis introduced by
amputation smgery. The poor contin-
Design ued to use crude crutches, peg-legs, or the Dutch surgeon Verduyn in 1696.
The earliest example of a prosthesis rolling platforms as they had fo r cen- With this prosthesis, the amputee was
for which we have visual evidence is tmies before (Figure 10). The increas- able to fully use the benefits of Ver-
the cosmetic hallux fitted in Egypt ing use of cannons and muskets, duyn's revolutionary posterior myo-
about 1000 BCE (Figure 7). A Roman meanwhile, made battle wounds an fasciocutaneous flap. It consisted of a
transtibial prosthesis circa 300 BCE ever-increasing cause of amputation copper socket lined with leather, a
had a wooden socket reinforced with as survival rates improved. Prosthetic solid ankle wooden foot, and a leather
bronze sheets. A mosaic fou nd in innovation finally began in the 16th thigh corset attached to the socket
France, of the .Gallo-Roman era, de- century, closely linked to the constant with jointed metal bars. The tightly
picts a hunter pursuing game on a warfare of that period. The first major laced thigh corset aided in both sus-
transtibial peg-leg (Figure 8). Pros- advance made during the Renaissance pension and weight bearing, while the
theses made by armorers for officer- (circa 1560) was by the French sur- joints allowed free knee motion (Fig-
amputees had the adcLitional benefit geon Pare who devised both an inex- ure 13). This became the prototype
of concealing the warriors' deficit pensive wooden kneewalker peg-leg for functional transtibial prostheses
American Academy of Orthopaedic Sul'geons

Figure 11 Pare;s kneewalker peg-leg for

poor private soldier-amputees. A, Front
view shows the flexed limb between me-
dial and lateral uprights resting on a
cushion. B, Posterior view. (Adapted from
Pare A: Ten Books of Surgery. 1563. Re-
Figure 9 The Teutonic knight Goetz von
Figure 10 Typical prostheses made for produced from the University of Georgia
Berlichingen holding a staff with his pros-
their own use by army veteran amputees Press, Athens, GA, 7969.)
thetic right hand, w hich featured jointed,
of the Renaissance period. The ankle dis-
locking f ingers to hold a weapon. (Repro-
articulate uses a kneewalker peg-leg and
duced from American Academy of Ortho-
paedic Surgeons: Atlas of Orthopaedic
cane. The knee disarticulate has a Anglesey leg after one was fitted to
weight-bearing peg-leg and a crutch. (Re- H .W. Bayly, Marquess of Anglesey,
Appliances. Ann Arbor, Ml, JW Edwards,
produced from American Academy of Or-
1960, vol 2, p 3.) who lost his leg in the closing mo-
thopaedic Surgeons: Atlas of Orthopaedic
Appliances. Ann Arbor, Ml, JW Edwards, ments of the battle of Waterloo in
1960, vol 2.) 1815 (Figure 15). Various modifica-
tions of tllis leg remained the stan-
until the introduction of the patellar
dard BTitish design until after World
tendon-bearing (PTB) prosthesis in With the increase in higher-level War I. In 1839, the design was
1961 by Charles Radcliffe and James gunshot injuries and the prevalence brought to the United States by Will-
Poort at the University of California of transfemoral amputees, there was a iam Selpho, a limb-maker in Pott's
at Berkeley. Nonetheless, the knee- growth of interest in the design of factory, as the "American" leg and was
walker peg-leg was still in common prostheses for this level with many in- thereafter modified by competitors.
use during the first half of the 19th genious devices as a result. The con- Martin and Charriere, in 1842, intro-
century. It was so ubiquitous, in fact, cept of an ischial weight-bearing duced another concept fundamental
that the ideal length of a transtibial socket had already been introduced to contemporary prosthetic and
amputation was held to be no more by Gavin Wilson in 1790. In 1810, J.G. orthotic design by offsetting the knee
than 8 to 10 cm below the knee joint von Heine, considered the founder of joint center posterior to the line of
to more conveniently fit this design. German orthopaedics, introduced weight bearing, gxeatly improving
Conceptual progress in upper limb ball-and-socket knee and ankle joints. stance phase stability. In 1860, capital-
prosthetic design continued with The knee joint was locked except izing on the 1839 invention of vulca-
Gavin Wilson's artificial hand (circa when sitting. In 1816, Peter Baliff also nized rubber by Charles Goodyear,
1790), capable of holding a knife, introduced a prosthesis with an inge- A.A. Marks of New York produced a
fork, or pen. Peter Baliff, a Berlin den- nious knee joint that unlocked on foot made of this material. This be-
tist, (circa 1816) developed the first toe-off to allow knee flexion during came the precursor of several designs
body-powered prosthetic hand acti- swing phase and relocked on heel of flexible feet popularized since
vated by elbow and shoulder motion contact to give stability during stance. World War II. Vulcanized rubber was
(Figure 14) . The concept of harness- In 1816, James Pott of London also quickly formed into rubber
ing the remaining muscles of a limb made a hollow-shanked wooden bumpers to limit and cushion the
to operate a terminal device remained transfemoral prosthesis with partially motion of prosthetic joints by Ameri-
central to all development in upper restrained ball-and-socket knee and can, British, and Continental prosthe-
limb prosthetics until the practical in- ankle joints and a toe hinge. The tists. It is of interest that Marks was
troduction of myoelectrically con - joints were connected by cords so that also the first to shrink-wrap wooden
trolled external power, beginning in knee flexion would dorsiflex the an- sockets and hollow shanks in rawhide
1958. kle. This leg became known as the for added strength and durability.

Figure 14 Transradial prosthesis de-

signed by Baliff circa 1816. Fingers are ac-
tivated by elbow and shoulder motion.
(Reproduced from American Academy of
Figure 12 Pare's transfemoral prosthesis Orthopaedic Surgeons: Atlas of Ortho-
designed for wealthy officer-amputees. paedic Appliances. Ann Arbor, Ml, JW Ed-
A, External view. 8, Note the leath er wards, 1960, vol 2.)
socket and metal shank and foot before
coverage with iron plates to resemble ar-
mor. (Adapted from Pare A: Ten Books of Figure 13 Transtibial prosthesis designed
proved with steel side joints, contin-
Surgery. 1563. Reproduced from the Uni- by Verduyn especially for amputees with
a posterior myofasciocutaneous flap. This ued in use until about 1929 as the
versity of Georgia Press, Athens, GA,
1969.) remained the prototype for transtibial "French" leg (Figure 17).
prostheses until the introduction of the Progress in prosthetics made dur-
patellar-tendon-bearing PTB prosthesis
ing the 19tl1 and early 20th centuries
by Radcliffe and Foort in 1961. (Repro-
The American Civil War resulted as a result of the Napoleonic,
duced from American Academy of Ortho-
in large numbers of amputees, aug- paedic Surgeons: Atlas of Orthopaedic Crimean, American Civil, and First
mented by the accident toll from the Appliances. Ann Arbor, Ml, JW Edwards, World Wars was influenced by a num -
expansion of industry and the rail- 1960, vol 2.) ber of critical factors that would con-
road system. After the war, the United tinue to play a role thereafter. Because
States experienced much more prosthetics has always been a small
growth in the development of pros- Neither suction suspension nor field that serves relatively few people,
thetic design and manufacture than endoskeletal construction became it has not always been possible, espe~
did Europe. One entrepreneur was widely accepted in the prosthetics cially for prosthetists themselves, to
James E. Hanger, a Confederate of- field until the latter part of the 20th devote the necessary time and fman-
ficer who lost his leg early in the war, century. cial resources to fully develop their
made a prosthesis for himself, and re- Despite the many profound con- concepts on any scale. In addition,
turned to battle. In 1861, he intro- ceptual changes in prosthetic design there was initially a limited number
duced a single-axis ankle joint con- of 19th -century innovators, the re- of materials available from which to
trolled by vulcanized rubber bumpers sulting limbs were affordable only by construct limbs, namely, wood,
rather than cords. He went on to the rich and by government- leather, and iron. Nonetheless, both
found the prosthetics company that subsidized war amputees. Civilian prosthetists and amputees have al-
bears his name to this day. Also, dur- amputees, who greatly outn umbered ways placed a premium on reliability,
ing the war, in 1863, Dubois Parmelee military ones, could not afford these strength, comfort, and low weight as
of New York was issued a patent for advanced limbs. With this age-old worthwhile goals, with cost of sec-
the first transfemoral prosthesis using problem in mind, the Comte de Beau- ondary importance. By necessity,
a suction suspension socket, eliminat- fort designed two inexpensive tran- prosthetists have had to borrow new
ing the need for elaborate body har- stibial prostheses, made entirely of techniques, devices, and materials, as
nesses or corsets. His prosthesis also wood and leather, for working men in they became affordable, from other
featured a polycentric roller knee 1867. One was a kneewalker peg-leg, fields that value these attributes and
joint, a multiarticulated foot, and en- and the other had wooden side joints then adapt them to their own use. In-
doskeletal construction at a time and a leather thigh lacer; each fea- novations of tl1e Industrial Revolu-
when most contemporary prostheses tured a rocker foot that made walking tion provided many opportunities for
were of exoskeletal design (Figure 16). much easier. The latter prosthesis, im- exploitation of new materials, meth-

Figure 15 Port's Anglesey Leg of 1816, in· Figure 17 The inexpensive Beauforttrans-
various modifications, was one of the Figure 16 Parmelee's endoskeletal transtibial prostheses of 1867 are made en-
most popular transfemoral prostheses for femoral prosthesis of 1863, featuring a tirely of wood and leather. A, Knee-
the next century. Internal elastic straps suction suspension socket. eliminating walker peg-leg. 8, Prosthesis featuring
are used to control movement of the the need for body harnessing. The lateral leather thigh lacer, locking knee j oints,
knee and ankle. (Reproduced from Amer- view shows the valve (arrow) placed in and adjustable leather socket. Both de-
ican Academy of Orthopaedic Surgeons: the distal-anterior socket, a polycentric signs have a rocker foot. (Reproduced
Atlas of Orthopaedic Appliances. Ann Ar- roller knee joint, and a multiarticulated from American Academy of Orthopaedic
bor, Ml, JW Edwards, 1960, vol 2.) foot. (Reproduced from American Acad- Surgeons: Atlas of Orthopaedic Appli-
emy of Orthopaedic Surgeons: Atlas of ances. Ann Arbor, Ml, JW Edwards, 1960,
Orthopaedic Appliances. Ann Arbor, Ml, vol 2.)
ods, and devices such as steel, vulca- JW Edwards, 1960, vol 2.)
nized rubber, and machine tools.
Another material that was adapted was the design of three- and four-bar
minum exoskeletal prostheses re- linkage knee joints by Alfred Haber-
to prosthetic use was aluminum, mained the British standard until well
which combines reasonable strength mann. Probably the most important
after World War IL American advance during this period
with light weight. Although Hermann Building on Parmelee's concept of
of Prague had substituted aluminum was the split hook for body-powered
suction suspension for transfemoral upper limb prostheses, invented and
for steel components as early as 1865, limbs, Ernest Underwood, a British
it remained for a fortuitous mishap to promoted by D.W. Dorrance, a trans-
war amputee, designed a wooden radial amputee. Terminal devices
lead to its fullest use in prosthetics. In
socket with annular spiral grooves based on his original design remain
about 1912, British test pilot Marcel
that closely fit the bare skin of the re- among the most commonly pre-
Desoutter lost his leg in a flying acci-
sidual limb. Fashioned of duralumin scribed options.
dent. Unhappy with heavy contempo-
a nd with a valve added, this became a During World War II, retLLrning
rary prostheses, he enlisted the help
successful design of the Blatchford military amputees quickly became
of his brother Charles, an aerona uti-
cal engineer and his partner in the firm. German designers were also ac- dissatisfied with the design and func-
aircraft manufacturing firm Desout- tive between the two world wars. The tion of available prostheses, especially
ter Brothers. Charles designed an exo- prosthetist Oesterlee of Ulm designed those for the upper limb, which com-
skeletal prosthesis weighing only 3.5 his own suction-suspension socket, bined excessive weight with little
pounds using the newly available alu- followed in 1932 by one with an im- function. In response to these persis-
minum alloy named duralumin. proved valve from the surgeon Felix tent complaints, Army Col. John
Word spread and soon Desoutter of Dusseldorf. The use of suction sus- Loutenh eiser enlisted the help of
Brothers became a prosthetic design pension was sufficiently widespread North rop Aviation engineers in 1943
and manufacturing firm. Demand in- in Germany by the end of World War to develop lighter weight and more
creased rapidly, despite the initial re- II to capture the attention of an functional upper limb prostheses. Us-
luctance of the British government to American commission charged with 0
ing a plastic laminate, socket weight
purchase these prostheses for war am- improving prosthetic care for US vet- and bulk were significantly reduced.
putees because of their high cost. Alu- erans. Another German development The Bowden cable, used to activate

aircraft control surfaces, was adapted metal pins with reflective targets to Actua lly, the Germans had been using
to operating upper limb prostheses, bony prominences of the lower limbs this method since the early 1930s,
replacing stretchable, fragile leather and pelvis of volunteers. Using based on Parmelee's American patent
thongs. Northrop engineers also in- interrupted-light photography, these of 1863. This technology was
vented a shoulder-operated locking markers allowed the accurate mea- promptly reintroduced to American
elbow for transhumeral amputees. surement of the relative motions of amputees. With the reintroduction of
That same year, the first prosthetic re- limb segments in three dimensions the intimately fitting suction suspen-
search laboratory was organized by during walking. These and other in- sion socket, the fixed-position hip
the Navy at Mare Island, California. novations formed the basis for the joint and pelvic belt were no longer
Before the war ended, a concerted field of biomechanics as we know it required, and coronal plane align-
national campaign was launched to today. Additional studies by J. Perry, ment of the prosthesis became more
address these same concerns, led by M.P. Murray, and others over the next critical. To meet this requirement, C.
the amputee veterans themselves, decades further enhanced our under- Radcliffe of UCB developed both an
strongly supported by Representative standing of normal and amputee gait. adjustable knee alignment unit and
Edith Nourse Rogers, Chairman of Within a short time, a network of an alignment-duplication jig to en-
the House Veterans Committee, and biomechanics laboratories was estab- sure accurate transfer of the three-
Secretary of War Stimson. The goal lished, each with a particular mission. dimensional configuration achieved
was to marshal the efforts of aca- UCB would continue to study the during standing and walking to the
demia and private industry to im- lower limb, while UC Los Angeles finished prosthetic limb.
prove prosthetic design. The redevel- (UCLA) would initiate a parallel bio- Significant improvements in pros-
opment of this partnership, which mechanical research program for the thetic knee joints soon followed. J.
had been so productive in the war ef- upper limb. Two major advances oc- Stewart, an engineer who was a trans-
fort, would lead to a new intellectual curred at UCLA. One was the devel- femoral amputee, developed a supe-
and clinical foundation for contem- opment of a rationale for socket and rior seal for a hydraulic shank unit of
porary prosthetics. The program harness design for every level of up- his design, which integrated ankle
eventually came under the auspices of per limb amputation. The second was dorsiflexion with knee flexion to clear
the National Academy of Sciences the design and testing of commer- the foot during swing phase. The seal
(NAS) with its Committee on Pros- cially available components that could also proved to be a great advance for
thetics Research and Development be assembled to meet the individual aircraft hydraulic systems. This latter
(CPRD) and Committee on Prosthet- needs of amputees. The Veterans Ad- application, as well as the prosthetic
ics and Orthotics Education. ministration Prosthetics Research one, was supported by Vickers Corpo-
In January 1945, the NAS orga- Laboratory in New York City, under ration of Detroit. Immediately after
nized a meeting in Chicago of leading the direction of E. Murphy, would the war, Hans Mauch, an engineer in
surgeons, engineers, and prosthetists, seek to apply the results of the UC re- charge of developing the German V-1
among them orthopaedists Paul Mag- search directly to war veterans with military rocket, came to the United
nuson of Northwestern University amputations. The Army Prosthetics States and resumed work on another
and P.D. Wilson of the Hospital for Research Laboratory at Walter Reed hydraulic knee unit with his ortho-
Special Surgery, to establish standards Hospital and the navy counterpart at paedic colleague, Ulrich Henschke.
for upper and lower limb prostheses. Oakland, California, would serve their The final result was a knee with hy-
It was soon determined that there was respective populations, the army con- draulic control of both swing and
insufficient scientific basis on wb ich centrating their efforts on upper )jmb stance, which is still in production.
to formulate any meaningful stan- prosthetic development and the navy The excessive weight of early hydrau-
dards. They recommended the orga- on lower limb. This aggregate body of lic units led the UCB laboratory to
nization of a government-funded work provided a solid rationale not develop a lighter pneumatic swing
program to undertake fundamental only to guide the future design and control knee unit, variations of which
studies related to prosthetic design, use of prostheses but to encourage remain in use.
fitting, and usage. Under the aegis of surgeons to save all possible limb By 1950, the UCB laboratory,
this program, basic studies of normal length and thus preserve more func- based on its anatomic studies, had de-
human gait were conducted at the tion than considered feasible before. veloped the ischial weight-bearing
University of California (UC) under Following reports of the wide- quadrilateral socket to replace the his-
the direction 9f Verne Inman, Profes- spread, successful fitting of transfem- toric plug-fit. The original concept
sor of Orthopaedic Surgery at UC oral prostheses with Sl!Ction suspen- had been brol!ght to England by the
Medical School in San Francisco, and sion by prosthetists in postwar West New Zealand prosthetist Nugent
Howard Eberhart, Professor of Civil Germany, the US Surgeon General 5 years earlier. Another major ad-
Engineering at UC Berkeley (UCB), dispatched a group of surgeons and vance of that decade for both upper
himself an amputee. They attached engineers to study this application. and lower limb prosthetics was the in-

troduction by Northrop Aviation of a In 1961, A. Stares of the National This design allows the shank to fold
thermosetting resin suitable for lami- Academy of Sciences fo rmulated cri- behind the thigh segment in full flex-
nating sockets on a plaster mold of teria for a temporary transfemoral ion, th ereby reducing the protrusion
the residual limb. This plastic lami- prosthesis for geriatric amputees, us- of the prosthetic thigh during sitting.
nate construction was used by re- ing a plastic socket attached to thigh The 1980s and 1990s saw several
searchers at the Sunnybrook Hospital and shank segments of metal tubing other significant technical advances
in Toronto in the mid-1950s for both joined by a knee hinge, complete with in lower limb prostheses, including
their new Syme and hip disarticula- a foot. This became the prototype for the development of prosthetic feet
tion prostheses. The new lightweight a variety of endoskeletal prostheses with internal leaf springs that en-
Syme prosthesis, with a removable initially produced by firms in Ger- abled amputees to walk, run, a1ld
window to facilitate donning and a many, the United States, and Britain jump with greater ease than ever be-
solid ankle-foot incorporating a cush- over the next decade. Prosthetic .ap- fore. Two major socket innovations
ion heel, reawakened interest in the plications fo r plastics developed by quickly spread from Iceland, where
Syme ankle disarticulation. Further the aerospace and other industries ac- they bad beea developed by amputee-
development of the solid ankle-cush- celerated, with sockets formed first prosthetist Ossur 1<risfinsson:
ion heel (SACH) foot continued at from thermosetting plastic and later flexible -walled sockets supported by
UCB with its application to transtib- from thermoplastics, such as polyeth- an abbreviated rigid weight-bearing
ylene and polypropylene. · frame and flexible roll-on suspension
iaJ prostheses. The hip disarticulation
By the 1970s, the German firm liners. This same -era saw Blatchford
prosthesis, designed by C. Mclaurin,
Otto Bock Orthopaedische lndustrie introduce the first prosthetic knee
featured a freely moving hip joint
GmbH had established a de facto offering microprocessor-controlled
mounted on the anterior surface of
worldwide standard by producing du- swing phase control, -demonstrating
the socket. Alignment stability of t he
rable and reasonably priced, inter- t he clinical value of self-adjusting
hip and knee joints permitted stand-
changeable endoskele.tal components components that can be programmed
ing and walkin g without a hip lock,
that could be realigned throughout to the individual needs of the ampu-
eventually rendering the previous
the useful life of the prosthesis with tee.
"tilt-table" prosthesis obsolete.
the result that the use of fixed- The advent of Computer Aided
In 1696, Verduyn had replaced the
alignment prostheses became increas- Design-Computer Aided Manufactur-
bent-knee peg-leg with the first pros- ing (CAD-CAM) systems for the pro-
ingly rare. Otto Bock also developed
thesis allowing knee motion by using the first reliable, lightweight endo- duction of prosthetic sockets became
a thigh corset and side joints for both skeletal knee incorporating a weight- possible with the introduction of
suspension and weight bearing. Two activated friction brake that automat- desktop computers in the 1980s, al-
hundred and sixty-five years later, the ically stabilized the knee throughout though the primary advantages to
UCB team of Radcliffe and Poort instance phase. In 1983, the old-line date have been increased manufactur-
troduced their total-contact PTB British fu-m Blatchford introduced a ing efficiency and incremental time
transtibia l socket, suspended by a 1.5-kg prosthesis formed primarily of savings compared to manual produc-
simple supracondylar strap, which carbon fiber- reinforced plastic com- tion of custom sockets. The ultimate
eliminated the need for Verduyn's ponent parts. Titanium, used exten- realization of the potential benefits of
thigh corset and side joints. sively in the aerospace and arms CAD-CAM may only come with the
Later suspension options for PTB industry, became a lightweight substi- development of input methods based
prostheses included extension of the tute for steel components. Another on more than just surface topography
socket brim over the femoral major advancement during the 1980s or perhaps via more sophisticated
condyles. These included the PTB su- was the introduction of the ischial socket design algorithms.
pracondylar (PTB-SC), developed by containment socket, which combined The initial work on external power
Kuhn in Muenster, Germany, and an increase of weight transfer area fo r the operation of upper limb pros-
the PTB-supracondylar-suprapatellar during stance phase at the limb- theses is attributed to the German
socket (PTB-SC-SP) by Fajal in socket interface with a narrow Borchardt in 1919. It remained for
Nancy, France. Further refinements of medial-lateral socket dimension more Russian investigators in the 1950s,
supracondylar suspension included closely matching the thigh anatomy however, to harness myoelectric sig-
various types of medial wedges. These than the earlier quadrilateral design. nals from the forearm extensor and
new suspensions, by their intimate Knee disarticulation began to gain tlexor muscle masses of transradial
clamp-Like fit just proximal to the more favor after the introduction by amputees to control the flow of elec-
femoral condyles, improved retention Eric Lyquist in 1973 of a reliable four- tric current from a battery contained
of the prosthesis while increasing bar linkage knee with hydraulic swing in the prosthesis. Further refinements
socket stability about the knee, partic- phase control, named the Ortho- by German, Austrian, American, and
ularly for short residual limbs. paedic Hospital of Copenhagen Knee. British companies have led to a vari-

ety of myoelectric hands, grippers, fitted, thus encouraging further devel- prosthesis) while the Germans made
and elbows to fit both adults and chil- opment of the field. During World the "Behelfsprothese" (temporary
dren. This expansion became possible War I, British philanthropists estab- prosthesis). Both were simple designs
with the availability, from industrial lished Queen Mary's Hospital for the resembling von Hessings' 19th-
applications, of solid-state circuits, ef- Limbless at Roehampton. Beset with century knee-ankle-foot orthosis with
ficient small motors, energy-dense wartime shortages and short-staffed jointed metal uprights, connected by
batteries, and more recently, micro- faci lities, British firms alone were un- bands encompassing a leather socket.
processors. Since 1976, technologic able to cope with the surge in demand To provide a p roper fit, the socket of
growth and development have contin- for prostheses created by the two the Arbeitsprothese was molded
ued unabated, and indeed, acceler- most common mechanisms; scything a.bout a plaster model of the ampu-
ated, due in large part to the incorpo- ma.chine gun fire and shrapnel. To tee's residual limb.
ration of spin-off technology from supply the necessary expertise and Prior to World War I, limb-fitting
the rapidly advancing cell phone, prostheses in sufficient quantity, the firms were vertically integrated, in-
pager, and handheld video game in- British, as the French had before cluding tl1e fabrication of compo-
dustries. them, turned to American prosthetic nents for their own use on a custom
firms to fill the void. They, along with or semicustom basis on demand. With
Socioeconomic Forces their British counterparts, were in- the experience gained by government-
Affecting the Provision of vited to locate facilities on the hospi- sponsored prosthetic facilities at-
tal grounds. For the first time, pros- tached to amputee hospitals, it be-
Prostheses
thetists and surgeons met at the came clear that greater production
From ancient times until the mid- patients' bedside to discuss their pros- capacity and cost-containment could
1800s, a prosthesis was a luxury avail- thetic restoration. The cumulative be achieved by a horizontal reorg<VJi-
able only to the wealthy. The relatively experience gained and knowledge zation, allowing mass production of
few poor who survived a major ampu- shared made Roeha.mpton renowned uniform components to be purchased
tation managed with homemade worldwide for excellence. At the same and used by many firms. The new ef-
crutches, peg-legs, kneewalkers, or time, the field of prosthetics began its ficiency would also allow component
rolling platforms, such as those seen in transformation from a cottage indus- manufacturers to devote the necessary
the paintings of Pieter Brueghel the try to a multinational business. The capital to exploit new materials and
Elder (1528-1569). Recognizing the Americans introduced designs, mate- techniques beyond the reach of indi-
huge socioeconomic disparity be- rials, and production techniques that vidual prosthetic fitters. With the
tween wounded officers and common were new to the British and French. 1919 foundi ng of Orthopaedische In-
peasant soldiers, Pare devised an inex- The characteristic feature of the dustrie GmbH in Berlin, Otto Bock
pensive wooden kneewalker peg-leg "American" leg included shoulder sus- introduced mass production of pros-
for the poor. The organization of spe- penders for cont rol of the knee in thetic components together with the
cial funds for the medical care of dis- swing phase, construction of the techniques for their alignment. The
abled workers started in the early shank from a single piece of wood, a three major lower limb modules were
1600s, with the European guilds. With single-axis foot controlled by rubber a socket block, a knee joint with
the decline of the guilds a century bumpers, and external reinforcement shank, and an ankle-foot assembly.
later, a variety of health funds were es- of wooden shank and thigh segments In anticipation of the need for a
tablished by manufactt!rers and trade with shrink-wrapped rawhide. greatly increased number of prosthe-
unions, but none paid for prostheses. The huge numbers of battle ampu- ses for American war amputees, the
The situation began to change, at tations forced the Central Powers chief medical officer of the Council of
least for military amputees, during (Germany and Austria-Hungary) to National Defense convened a meeting
the American Civil War, when both drastically change their methods of of the 10 lea.ding American prostl1etic
the Federal and Confederate govern- prosthesis manufacture and provi- firms in 1917. This meeting resulted
ments began to provide prostheses at sion. For the first time, anthropomor- in the formation of the Association of
public expense. The original Federal phic measmements of the lower Limb Manufacturers of America that
legislation of 1862 was amended in limbs, developed by the Berlin ortho- eventually became tl1e American
1870 to allow a new prosthesis every 5 paedist Professor Gocht, were used to Orthotic and Prosthetic Association,
years, and later to every 3 years. The help design simple prosthetic compo- which remains the preeminent trade
Prussians and British quickly fol- nents that could be produced quickly. organization for these fields in the
lowed suit, providing both an articu- In this way, wounded soldiers could United States. Because of the late en-
lated prosthesis and a peg-leg to wear be rapidly deployed to supportive ag- try of the American Expeditionary
during repairs on the primary pros- ricultural or war factory work. The Force into tl1e war, however, the num-
thesis. These measures substantially Hungarian military surgeon Dollinger ber of US amputations totaled 4,403,
increased the number of prostheses produced the "Arbeitsprothese" (work of which 2,635 were considered ma-
American Academy of Orthopaedic Surgeons j

Ch apter I: The Histor y of Amputatio,n Surgery and Prosthetics 17
jor, as compared to 42,000 for the New York University under the direc- Further VA-sponsored courses for
British, allowing the redeployment of tion of Sidney Fishman. To assist in clinic teams followed. UCLA pre-
American prosthetists to the United the widest possible dissemination of sented 12 six-week col!rses on upper
Kingdom as described previously. this new knowledge in a timely man- limb prosthetics during 1953 ru1d
During World War II, United ner, the Child Amputee Clinic Chiefs 1954. The response was so great that
States forces sustained 17,130 ampu- inaugurated an annual meeting and prosthetics education programs were
tations. With thousands of American SCPP began publication of the Inter- established at New York University's
amputees returning home throughout Clinic Information Bulletin (ICIB) . Postgraduate Medical School in 1956
World War II, the Army and Navy re- With the dissolution of CPRD in 1976 and in 1959 at Northwestern Univer-
sponded by establishing specialized and with it SCPP, the Association of sity. The national program reached its
centers for their overall care, i11clud- Child Prosthetic and Orthotic Clinics peak in the late 1980s when 12 uni-
ing all aspects of prosthetic rehabilita- (ACPOC) was formed to fill the void versities offered preparntory pro-
tion; ten for the Army and two for the and continue publication of the ICIB, grams in prosthetics and orthotics.
Navy. These centers incorporated the later known as the Journal of the Asso- Five were at. the baccalaureate level,
work of surgeons, prosthetists, and ciation of Child Prosthetic and Orthotic while seven offered postgraduate cer-
therapists working as a team. By 1945, Clinics. Unfortunately, the journal tificates in prosthetics, orthotics, or
the Army Center in Walter Reed Hos- ceased publication in 1994. both disciplines. By 2000, fledgling
pital was receiving up to 1,500 ampu- master's level progrnms had begun
tees each month. In 1965, the Medi- Education and Training in and doctoral programs existed in
care program began to provide Prosthetics Scotland, Hong Kong, and Australia.
prostheses for US citizens older than Unfortunately, chronic reductions in
Prior to World War II, training in
age 65 years and younger persons per- federal funding for prosthetic and
prosthetics was largely based on in-
manently disabled by amputation. orthotic education led to the demise
formal apprenticeships. The wide-
This trend reversed in tl1e 1990s, of thre,e entry-level baccalaureate pro-
spread and vocal dissatisfaction of
when managed care organizations ei- grams by the new millennium.
war amputees with the available pros-
ther began excluding prostl1eses from The first English-language periodi-
thetic designs led to a massive
coverage or limited benefits to "on e cal for prosthetists appeared in 1946
per lifetime" or an aD11ual maximum government-sponsored reseaTch and
as the Orthopaedic and Prosthetic Ap-
reimbursement of as little as $1,000. development program. In 1949, UCB
pliance Journal, published by the fore-
With advances in prosthetic de- gave a pilot co urse in the prescrip- runner of AOPA. In 1976, the Ameri-
sign, manufacture, and provision well tion, fabrication, and alignment of can Academy of Orthotists and
w1derway for the war amputee popu- the suction-suspension transfemoral Prosthetists (AAOP) began their own
lation, attention turned to another socket recently readopted from Ger- journal. The two journals merged in
group whose caTe badly needed reor- many. This was followed by local 1988 to become the quarterly Journal
ganization: children with limb defi- courses in key areas of the country, of Prosthetics and Orthotics. The Pros-
ciencies. In 1952, the United States sponsored jointly by tl1e Veterans Ad- thetic and Sensory Aids Service of the
Chilmen's Bureau assisted the Michi- ministration (VA) and the limb man- Department of Veterans Affairs in
gan Crippled Children's Commission ufacturers' association that is now 1964 began publishing what has be-
in organizing the first Child Amputee known as the American Orthotic and come the Journal of Rehabilitation Re-
Program in the United States. It was Prosthetic Association (AOPA) . There- search and Development, which ap-
located in Grand Rapids, Michigan, after, the VA organized 30 amputee pears bimonthly with additional
under the direction of orthopaedists clinic teruns for their hospitals, each supplements. In the late 1950s, having
C.H. Frantz and G.T. Aitken. A simi- consisting of a surgeon, prosthetist, realized the need for an international
lar program was established in 1955 physical and occupational therapist, exchange of information on prosthet-
at UCLA and both continue to serve and a VA prosthetic representative. As ics, orthotics, and amputation sur-
this population today. In 1956, the a result of tl1ese actions, a strong de- gery, The International Committee on
Committee on Prosthetic Research sire arose on the part of prosthetists Prosthetics and Orthotics (ICPO) be-
and Development (CPRD) of the Na- to elevate their educational and pro- gan publication of a technical journal.
tional Academy of Sciences estab- fessional status to match that of other ICPO evolved into the present-day
lished the Subcommittee on Child terun members. In 1949, the American International Society for Prosthetics
Prosthetic Problems (SCPP), chaired Board for Certification in Prosthetics and Orthotics (ISPO), and its publi-
successively by Ors. Frantz and Ait- and Orthotics (ABC) was formed to cation became Prosthetics and Ortlwt-
ken. To further evaluate devices and establish standards for examination ics International, published three
techniques resulting from these and certification of individual practi- times a year. In cooperation with the
projects, a Child Prosthetics Studies tioners and tl1e accreditation of pros- World Health Organization (WHO)
program was funded tl1e same year at thetic and orthotic facilities. and the International Committee of

the Red Cross (IC RC), JSPO has de- too disabled to serve again, leaving bilitation of amputees prior to their
veloped standards for prosthetic and them to beg for subsistence. Even for separation from military service. By
orthotic education programs and the few who obtained prosthetic 1945, the army had 10 amputee cen-
clinical care delivery systems for de- limbs, there was no organized care ters and the navy had two.
veloping nations. ISPO also sponsors with a goal of societal reintegration. In Success in these military programs
a triennial World Congress and peri- 1867, the Prussian government was was replicated for civilians by the es-
odic international consensus confer- the first to legislate not only prosthetic tablishment of interdisciplinary am-
ences and update courses throughout restoration but hospitalization for ac- putee clinics. Many of the advances in
the world, cosponsored by local pros- commodation to walking with the amputee rehabilitation in the latter
thetic and orthotic organizations. The prosthesis. The British also began pro- half of the 20th century resulted from
charitable German Society for Techni- viding prostheses for the war wounded this close collaboration between phy-
cal Cooperation (Deutsche Gesell- during this period, but it was not until sician, surgeon, prosthetist, therapist,
schaft fuer technische Zusammenar- 1915 that Queen Mary's Hospital for and other professionaJs who shared a
beit [GTZ]) has been one of the most the Limbless (Roehampton) was es- commitment to amputee care. In re-
effective prosthetic and orthotic out- tablished where physicians and pros- cent years, changes in the econom ics
reach groups. GTZ has organized thetists were brought together with the of health care have reversed this
prosthetic and orthotic training pro- patient. During this time, the Central trend, as postoperative hospitaliza-
grams in several countries in Africa, Powers also began fitting early tempo- tions become increasingly brief and
Asia, and Latin America, successfully rary prostheses to speed the return of outpatient treatment becomes the
turning them over after a time to local war amputees to useful work in facto- norm for new amputees. It has proven
instructors whom they have trained. ries and farms. The US government difficult to replicate the fertile inter-
In 1970, the AAOP was formed also established seven widely dispersed change of ideas among team members
with a primary focus on education, stateside amputee centers at Walter that was inherent in the formal am-
modeled after the American Academy Reed General Hospital in Washington, putee clinic, now that they often func-
of Orthopaedic Surgeons. Shortly DC; Letterman General Hospital in tion in geographic isolation from one
thereafter, in 1972, ABC commis- San Francisco, California; Fort Des another.
sioned the development of standards Moines in Iowa; Fort Snelling in Min-
nesota; Fort McPherson in Georgia;
for educational programs in prosthet-
General Hospital 3 in New Jersey; and
Summary
ics and orthotics. These standards are
General Hospital 10 in Boston, Massa- Historically, advances in amputation
carried out by a new independent
chusetts. Another concept that would surgery have been closely linked to
body, now called the National Com-
later be resurrected after World War II armed conflict, in turn spurring im-
mission on Orthotic and Prosthetic
was the fitting of an immediate post- provements in prosthetic technology
Education, which approves education
operative prosthesis (IPOP), begun by and care. These trends have acceler-
and residency programs in these
the Frenchman Depage in 1917. Ber- ated during postwar periods when-
fields, in cooperation with the Com-
lemont and Weber resumed this ever attention and resources have
mission on Accreditation of Allied
method in 1957, followed by Marian been focused on amputee veterans.
Health Education Programs. The
Weiss of Poland who reported on his Advances in military rehabilitation
AAOP has been a major force in ad-
extensive experience in 1963, stimulat- have, in turn, been incorporated i11to
vancing the level of prac~itioner edu- ing research by E.M. Burgess in Seattle, civilian practic~ and developed fur-
cation and clinical practice in pros-
A. Sarmiento in Miami, and the Navy ther whenever adequate funding has
thetics and orthotics, sponsoring an Prosthetic Research Laboratory in been established. Better surgery and
ever-growing array of continuing ed- Oakland. sockets after World War II led to de-
ucation conferences and review During their World War II occupa- mands for more sophisticated com-
courses each year. In 2003, the AAOP tion, the Dutch set up a rehabilitation ponents, which were first developed
inaugurated an ongoing series of con- center for their wounded soldiers. based on government research fund -
sensus conferences to develop clinical The program included physical ther- ing and later from commercial invest-
standards of practice, patterned after apy, sports therapy, and job placement. The level of prosthetic educa-
the successful multidisciplinary con- ment. During this time, a similar tion has gradually risen since World
sensus conferences hosted by ISPO. program was in operation at Roe- War II, along with the technical so-
hampton in England. The Dutch pro- phistication of the materials, meth -
Emergence of Amputee
gram of amputee rehabilitation was ods, and components used, while ed-
Rehabilitation expanded in the 1950s to include in- ucation in amputation surgery has
Until the 19th century, the govern- jured workers. In the United States, declined. Only time will tell whether
ments that recruited men to fight their the Army Surgeon General estab- the recent fragmentation of the clinic
wars typically turned away from those lished specialized centers for the reha- team and reduction in funding for

Chapter l: The History of Amputation Surgery and Prosthetics 19
prosthetic rehabilitation and training Garrison FH: An Introduction to the His- Sanders GT: Lower Limb Amputations: A
in amputation surgery is a temporary tory of Medicine, ed 4. Philadelphia, PA, Guide to Rehabilitation. Philadelphia, PA,
setback or the harbinger of a new era WB Saunders, 1929. FA Davis, 1986.
in which the pace of advancement in Guyatt M: Better legs: Artificial limbs for Weir RFff, Heckathorne CW, Childress
amputee care will diminish. British veterans of the first World War. DS: Cineplasty as a control input for ex-
J Design Hist 2001;14:307-325. ternally powered prosthetic components.
]Rehabil Res Dev 2001;38:357-363.
Acknowledgment Historical development of artificial limbs,
in Orthopaedic Appliances Atlas. Ann Ar- van der Meij WKN: No Leg to Stand On.
The au thors wish to express their bor, MI, JW Edwards, 1960, vol 2, pp l -22. Historic:al Relation Between Amputation
thanks to Mrs. Eugenie Henry for her Surgery and Prostheseology. Gronigen, the
Nerlich A, Zink A: Eine Zebenprothese an
expert preparation of this manu- Netherl ands, AE Brinkman, 1995.
einer altaegyptischen Mumie. Med Orth
script. Tech 2002;122:32-33. Wilson AB Jr: History of amputat ion sur-
gery and prosthetics, in Bowker JH,
Pare A: On Gangrenes and Mortifications,
Michael JW (eds): Atlas of Limb Prosthet-
Selected Readings book VII in Ten Books of Surgery With the
ics: Surgical, Prosthetic, and Rehabilitation
Magazine of the Instruments Necessary for
Ellis H: Famous Operations. Media, PA, Principles, ed 2. American Academy of
It, 1563. Translated from the French by
Harwal Publishing, 1984. Orth opaedic Surgeons, Rosemont, IL,
RW Linker and N Womack. Athens, GA,
2002, pp 3-15. (Originally published by
Furman B: Progress in Prosthetics. Wash- University of Georgia Press, 1969.
Mosby-Yea r Book, 1992.)
ington, DC, US Government Printing Of- Phillips G: Best Foot Forward: Chas. A.
fice, 1962. Blatchford & Sons Ltd (Artificial Limb Spe-
cialists) 1890-1990. Cambridge, England,
Granta Editions, 1990.

General Principles ofAmput(!,tion
Surgery
Introduction
Arms and legs, hands and feet: These Amputation surgery severs all the the residual limb. Reconstruction
unique and wonderful extensions of varied tissues of the limb. Each tissue must promote primary or secondary
the body allow humans to touch, to must heal in its own particular man- wound healing as well as create the
feel, and to manipulate the environ- ner, and the knowledgeable surgeon most functional residual limb possi-
ment. They provide the invaluable ca- considers the unique role of each tis- ble. The reconstructive nature of am-
pability of propulsion and allow free sue when planning the course of re- putation surgery and the positive im-
movement. The word limb hardly construction. This careful calculation pact proper technique can have on an
captures the essence of these magnifi- is essential to create the most func- individual's postamputation function
cent structures. tional residual limb possible. Limb cannot be overemphasized. The suc-
Loss of part or all of a limb forever loss is not only a major physical and cess of every amputation surgery de-
changes how a person moves, touches, functional loss, it also presents the pa- pends on the balance between removal
works, and plays. The individual who tient with an enormous psychological and reconstruction. To provide the
loses a limb faces enormous emo- and emotional challenge. Limbs not best ca1·e for each patient, the surgeon
tional, psychological, and physical only are a major part of the physical must thoroughly understand not only
challenges and may perceive himself being but also contribute to the indi- surgical principles but also all the as-
or herself as no longer whole. To re- vidual's body image and self-image. pects of healing, rehabilitation, and re-
gain lost function, the most common Losing a limb alters all these aspects of sidual limb physiology and the nature
option is to supplement the newly al- the amputee's life. When a limb or of prosthetic devices.
tered physical body with a prosthesis. portion of a limb is removed, the brain The team approach to amputee re-
This is how many amputees find peace continues to perceive sensations, habilitation leads to more successful
and wholeness. movement, and even pain in the tis- healing and a better informed patient.
One young transfemoral amputee sues no longer physically present. As Communication among team mem-
recently advanced her vision for those Burgess2 has pointed out, no amount bers is essential. The surgeon is but
with limb loss. 1 Her hope is that in of psychological testing and evalua- one member of the amputation reha-
the future, amputees will be offered tion can completely measure the ef- bilitation team and can benefit from
not "artificial" limbs but "replace- fects oflimb loss on a given individual. the wisdom and perspectives of the
ment" limbs. Replacement limbs Only the amputee knows what it is like other team members throughout all
would be so comfortable, natural, and to lose a limb and how that loss im- phases of the process-the preopera-
functional that limb loss would be- pacts his or her life. 3 tive evaluation, during surgery, dur-
come a much less significant event, The surgeon has a unique responsi- ing the early postoperative healing
similar to the loss of an appendix or a bility to achieve two goals, both of phase, and through management of
gallbladder. This goal, of minimizing which are critical to the success of an late complications long after the de-
the impact of an an1putation on the amputation. The first goal is the re- finitive surgery is complete. Surgeons
patient, is one toward which sur- moval of the diseased, damaged, or would be wise to encourage opinions
geons, prosthetists, and rehabilitation dysfunctional portion of the limb. The from their teammates and take these
specialists all strive. second goal is the reconstruction of opinions into consideration.

Surgical Levels of Amput?1tion length is a basic principle of modern

amputation surgery. Nevertheless, the
Considerations Amputation levels developed through
surgeon must balance skeletal length
tradition, as surgeons passed down
General Considerations and soft-tissue reconstruction to pro-
knowledge and lessons learned about
Amputation is a broad term that has vide a well-healed, nontender, physio-
specific techniques. The best tech-
been used to cover the entire range of logic residual limb.
niques provided the fastest healing, as
body-part loss, from the loss of part In determining amputation level,
well as a residual limb that was well
of a finger to scapulothoracic ampu- the goal is to create the best environ-
padded and could best retain its phys-
tation and from the loss of a toe to a ment for the rapid return of mobility
iology. Specific amputation levels
pelvic or even a translumbar amputa- and function, and this ideal environ-
were determined by bow well they ac-
tion. However, it is more precise to re- ment will be different for each pa-
commodated prosthetic fitting. tient. For example, the patient's nutri-
serve the term amputation for the Controversies still exist concerning
process of removing a limb by divid- tional status will play a role in wound
the most appropriate level of amputa- healing. For patients with diabetes
ing through one or more of the bones tion. As would be expected, not all
and to use the term disarticulation for mellitus, controlling blood glucose
surgeons agree on the best course of levels is essential. In all cases, mini-
the process of removing a limb by di- action in specific cases. In instances of
viding between joint surfaces. Each mizing edema, optimizing vascular
lower limb injury, an ankle disarticu- inflow, an d eliminating bacteremia
particular site throughout the upper lation and a knee disarticulation both through appropriate use of antibiotics
or lower limbs has unique anatomy have advantages and disadvantages. are essential to determining amputa-
involving bone shape, nerves, muscu- This makes selecting between these tion level. All surgical procedures
lature, and blood vessels, as well as levels controversial, not because the must be coordinated with rehabilita-
available muscles and skin and soft- techniques are questionable-most tion plans to minimize decondition-
tissue envelope available for padding, surgeons agree that the techniques are ing. Amputee management requires a
protection, and reconstruction. When practicable-but because success multidisciplinary approach to address
deciding where and how to amputate, rates and ease of prosthetic fitting re- these issues. Medical, surgical, social,
the surgeon should have an intimate main disputed. In the past decades, rehabilitative, prosthetic, and eco-
understanding of the anatomy of the improvements in design a11d engi- nomic factors all play an important
different sites and the various at- neering of prosthetic devices have role in each case. Planning for opti-
tributes and characteristics that affect made these amputation levels much mum function in amputation surgery
healing and prosthetic rehabilitation. more successful. Today, even conser- requires continual evaluation and re-
vative surgeons are apt to consider evaluation of preoperative, surgical,
Limb Salvage Versus
ankle and knee disarticulations to be and short- and long-term postopera-
Amputation viable surgical procedures. tive goals.
The decision between limb salvage In each case, the surgeon faces a
and amputation depends on different vast number of decisions and has
considerations for the upper and considerable latitude to exercise per- Skin
lower limbs.4 For example, the upper sonal judgment. All options must be In amputation, the general principles
limbs are not weight bearing and can weighed thoughtfully and thoroughly. of plastic and reconstructive surgery
function with minimal ~ensation. A The initial and most basic decision is apply to incision location and scar
salvaged upper limb, even with only the choice between amputation and placement. A painless, pliable, and
minimal assistive function, is often salvage. Once amputation has been nonadherent scar is a primary goal in
better than the upper limb prostheses decided upon, the surgeon must de- most surgeries, but in amputation,
available today. In contrast, weight termine the most distal level of am- the prosthetic interface and socket de-
bearing is an essential function of the putation still compatible with wound sign may make the location of the
lower limb, so a salvaged lower limb healing and subsequent satisfactory scar even more important. When un-
must provide durability and protec- prosthetic fitting. Level selection re- complicated primary healing occurs
tive sensation sufficient to hold up to quires detailed clinical evaluation and the resulting scars are nontender,
the demanding forces of walking and combined with appropriate labora- pliable, mobile, and durable, then scar
weight bearing if it is to function as tory and radiographic studies. Except location does not really matter. When
well as or better than a prosthesis. in special circumstances, as discussed healing is less than ideal, however,
When salvage is not possible and am- in chapters on each particular level, and the scars become adherent, ten-
putation is the best course of action, surgeons should select the most distal der, thin, nondurable, thick, or prom-
the patient and the rehabil itation amputation level that successfully re- inent, then location matters a great
team should be aware of these differ- moves diseased or damaged tissue. deal. The wise surgeon plans scar
ences between upper and lower limbs. Preserving functional residual limb placement to minimize potential fu-

Chapter 2: General Principles of Amputation Surgery 23
ture complications in the event of grafted skin and burn tissue will tol- contract, progressive weakness and at-
less-than -perfect healing. erate more pressure over time if the rophy develop. Distal muscle stabili-
With lower limb amputations, the shear and skin stretch are minimized zation is therefore a primary goal of
amputation site functions as the pa- by careful prosthetic fitting. A gradual amputation surgery. Whenever possi-
tient's foot and, therefore, requires reintroduction to wearing the prosthe- ble, the sectioned muscle should be
constructive design to provide a dura- sis will also help establish tolerance. attached and stabilized in order to re-
ble interface with the socket for The amount of time wearing the tain muscle function and improve
walking and the transfer of body prosthesis, the amount of force ap- coverage and distal padding of the
weight. With upper limb amputa- plied, and the activity levels must be bone.
tions, the amputation site becomes, in carefully controlled and slowly in- Four types of muscle stabi lization
essence, the patient's hand. The skin creased. Even a badly burned residual can be accomplished surgically, in-
should therefore be managed as care- limb with free graft coverage may be- cluding simple myofascial closure,
fully as it would be in hand surgery to come accustomed to a prosthetic de- myoplasty, myodesis, and tenodesis.
ensure the most successful outcome. vice over a period of many months, T hese have varying degrees of efficacy
allowing it to provide optimum func- and efficiency in terms of muscle sta-
Fasciocutaneous Flaps tion and thereby avoiding reamputa- bilization and preservation of func-
Fasciocutaneous flaps should be made tion at a higher anatomic level. tion.
as broad based as possible to maxi-
mize perfusion and avoid compro- Long-Term Concerns Myofasci al Closure
mising blood supply. 15 The skin clo- Skin problems remain a major con- The first of these techniques, myofas-
sure must be without tension but also cern for amputees throughout their cial closure, encases the bone and
without redundancy. Par ticularly in lives. The surgeon needs to be famil- transected muscle by simply closing
the dysvascular limb, care must be iar with the many different types of the outer fascia! envelope over the top
taken to avoid separating the skin potential short- and long-term skin of the muscles. Myofascial closure it-
from the underlying subcutaneous and wound-healing problems. Post- self does not effectively stabilize mus-
tissue and fascia. Care should be operative infections, wound dehis- cle because it provides only minimal
taken not to place scars over a bony cence, and partial skin flap failure oc- stabilization for the most superficial
prominence or the subcutaneous cur with unfortunate frequency in the muscles and it does not provide ade-
bone. The more skin surface that is early postoperative phase. Contact quate distal attachment of the muscle
available for contact with the pros- dermatitis, skin irritation, reactive hy- tissue to the bone. Myofascial closure
thetic socket, the less pressure will be peremia, callus formation, verrucous is used primarily when severe is-
applied to each unit area of skin sur- hyperplasia, folliculitis, epidermoid chemia prevents more effective distal
face. A cylindrically shaped residual cysts, hidradenitis, fungal i11fections, muscle fixation. 6 - 8 Even in most dys-
limb with muscular padding presents and chronic breakdown are potential vascular and diabetic amputations,
fewer skin problems than a bony, long-term skin ailments. Complicated however, more effective muscle stabi-
atrophic, tapered residual limb. skin problems often require multidis- lization is almost always technically
ciplinary approaches involving pros- possible and should be attempted.
Skin Grafts thetists, wound care specialists, der-
Along with fasciocutaneous flaps and matologists, and the original surgical Myoplasty
free-flap techn iques, skin grafts can team. In most diaphyseal amputations,
be a viable option. Split-thickness which includes most transfemoral
skin grafts can withstand forces ap- and transtibial amputations, the mus-
plied by a prosthesis, but grafts will be
Muscle cle beUies themselves are transected,
most successful when they do not ad - Muscle makes up the bulk of the soft making it more difficult to attach the
here to bone. Application of the graft tissues of the residual limb. A muscu- muscle to the bone than when the
over a cushioned, mobile muscle bed lar, well-padded, and balanced resid- thicker distal fascia, aponeuroses, or
is ideal. Without the fine layer of sub- ual limb is less prone to chronic pain. tendons are still present. In these in-
cutaneous fat to absorb shear, how- Maximum retention of functioning stances, myoplasty has been em-
ever, grafts are not as durable as nor- muscles is essential to provide the re- ployed. In myoplasty, the surgeon
mal skin. Fortunately, socket liners sidual limb with effective strength, brings the muscles over the end of the
made of elastomeric materials have size, shape, circulation, metabolic ex- bone and sews them to opposing
improved prosthetic success for indi- change, and proprioception. Proper muscle groups. Unfortunately, unless
viduals with scar and skin grafts. This muscle function depends on the ana- these muscles become firmly stabi-
is especially helpful for burn survivors tomic origin and insertion of the lized by scar tissue, the attachment
because amputations on burned muscle. Without fixed resistance can work antagonistically as a muscu-
limbs often require skin grafts. The against which a muscle can forcefully lar sling, sliding back and forth over

the distal end of the bone. This slid- and determining the appropriate ten- pulsating vessels. Nerve ligation is in-
ing of muscle over bone creates bursal sion level does not follow a set of dicated if the nerve is likely to bleed,
tissue and can cause severe pain. Such hard-and-fast rules. Studied clinical as is the case with the sciatic nerve.
a scenario is easy to detect on physical judgment and adherence to the prin- When a nerve is severed in the ampu-
examination because both the motion ciples of muscle tension provide the tation, tl1e surgeon's goal is to posi-
and the accompanying crepitance will best results. Determining correct tion the nerve ending in a well-
be palpable over the end of the bone. muscle tension in an amputation is cushioned area of soft tissue away
Because of the frequency of these similar to determining the tension of from the incision and any scar tissue,
complications, simple myoplasty by tendon transfers in the hand or foot. where the nerve will not be irritated
itself is not usually recommended. In general, most surgeons err on the by traction, pressure from the pros-
The surgeon should instead attempt side of too lax rather than too tight. thetic socket, or any other potential
to secure the tissue directly to tl1e dis- Excessive or unbalanced tension can sources of contact.
tal end of the bone. This is called my- cause severe pain. For example, exces- Neuromas that form in very
odesis and, used with myoplasty, can sive tension can occur in transfemoral scarred and adherent areas are the
be a very effective means of muscle amputation if a surgeon advances the most symptomatic. When working in
stabilization. quadriceps too far distally, leading to these areas, the surgeon should apply
hip flexion contracture. moderate tension to the nerve and
Myodesis section it cleanly, aUowing it to retract
In myodesis, the muscle groups them- away from the site of amputation and
selves are attached directly and se-
Nerves into the proximal soft tissues. This
curely to the periosteum or the bone. The management of sectioned nerves prevents scarring of the distal end of
Typically, the deepest layers of muscle remains a controversial aspect of am- the nerve to the surgical site, where
are secured directly to the bone and putation surgery. The free end of a di- traction and pressure are more likely.
the more superficial layers of muscle vided nerve heals by forming a neu- Traction on the nerve at the time of
are sewn to each other as a myoplasty. roma. This intertwined mass of scar sectioning should not be excessive be-
The myofascial envelope is then and nerve tissue can become painful cause too much tension can lead to
closed over the top of this muscular to pressure, stretching, and other proximal pain and neuropathy. As
reconstruction. 4 types of physical manipulation. Even with the conservation of muscle tis-
when the neuroma is completely un- sue in the residual limb, the surgeon's
Tenodesis disturbed, electrical potentials may goal is to retain and employ as much
A final muscle stabilization technique arise within the mass, causing nega- useful nerve function in the residual
is tenodesis. Tenodesis involves the tive local and distant sensory and mo- limb as possible. Care should be taken
firm distal attachment of the severed tor phenomena that can be bother- to avoid disturbing the nerve fibers
tendon to the bone and is the most some and painful to the amputee. innervating limb structures that are
physiologic and effective way to stabi- Numerous techniques have been de- still intact, particularly those inner-
lize muscle. However, it is often not vised to minimize neuroma forma- vating the muscles and skin.
possible anatomically. It is possible tion, but none has proven uniformly The theory that the proximity of
only when the muscle belly itself is successful. Methods include cauteriz- nerves and blood vessels can cause
not transected and the tendon is ining the nerve ends using chemicals or symptoms is attracting renewed inter-
tact. Tenodesis is most commonly heat, burying the nerve in bone, en- est. When a nerve is unintentionally
used in disarticulations. It is the pri- casing the nerve in impervious mate- ligated with a pulsing artery, the
mary method used in knee disarticu- rial, ligating the nerve, or injecting nerve endings may sense the vessel's
lations, in which the patellar tendon the nerve with a variety of chemicals. cadence and become a source of pain-
is secured to the origin of the cruciate Other methods include sewing the ful throbbing. In the transtibial am-
ligaments on the distal femur. When- sectioned nerves to other nerves or putation, the two nerves most com-
ever anatomic circumstances permit, sewing them back onto themselves, monly ligated with a vessel are the
distal attachment of the muscles, ten- thereby creating a nerve loop, or sim- deep peroneal nerve and the tibial
dons, fascia, or aponeuroses directly ply dividing the nerve and allowing it nerve. This happens if the deep pero-
to the bone should be performed. to retract. neal nerve is not separated from the
Because none of the new methods anterior tibial vessels or if the tibial
Stabilization has demonstrated a lower rate of nerve is not separated from the poste-
To optimize effective muscle activity symptomatic neuromas or phantom rior tibial vessels. A revision surgery
in the residual limb, the muscle pain, the generally accepted proce- in which the nerve is separated and
should be stabilized under near- dure is to draw the nerve distally, sec- divided away from the vessels can re-
physiologic tension. Correct muscle tion it, and allow it to retract away lieve the throbbing. Extra caution
tension varies in different situations, from areas of pressure, scarring, and concerning the nerves should always

be exercised in high-level upper limb particularly when blood supply is amputation can also help prevent fu-
amputations. Unfortunately, particu- marginal. ture complications.
larly in surgeries involving the bra- Amputation sites are usually closed Proper attention to .bone prepara-
chial plexus, nerves are often inad- over suction drainage because section eliminates potential areas of high
vertently included in the ligatures tioned muscle and bone can often re- pressure at the bone-socket interface.
with the axillary vessels. sult in a surgical site that is not per- In the normal anatomy, there are no
fectly dry. The surgeon should make sharp, angular surfaces in the palm of
every effort to avoid a postoperative the hand or the sole of the foot, and
Blood Vessels hematoma; however, in the event one retained distal bone in the residual
does form, it must be identified early limb, which will function as a hand or
Adequate hemostasis and the man-
and treated quickly. A postoperative foot, should come as close to this nat-
agement of blood vessels and bleeding
hematoma can predispose the patient ural state as possible. Occasionally in
sites are of utmost importance in am-
to infection, delayed wound healing, disarticulations, it is wise to narrow
putation surgery. Major arteries and the distal metaphyseal flare of the
or complete failure. Revision surgery
veins should be isolated and ligated bone to prevent an overly bulbous
and higher level amputation have
securely. Double ligation of large ar- and enlarged distal end. For example,
been required because of hematomas.
teries should be standard, especially in the Syme ankle disarticulation, sur-
If a large postoperative hematorna is
when the blood supply is normal. gical contouring of the distal tibia
identified, therefore, the patient
Cauterization should be reserved for and fibula are mandatory because a
should be returned to the operating
smaller bleeding points only. The cen- bulbous and noncontow-ed distal end
room for evacuation, irrigation,
tral artery of a large nerve, such as the will cause difficulties in prosthetic fit-
debridement, and hemostasis. Com-
sciatic nerve, can be a source of trou- ting. In general, however, bone resec-
plete hemostasis should be achieved
blesome bleeding. In this instance, ex- tion is kept to a minimum in most
before the patient leaves the operating
cessive bleeding can be avoided by disarticulations.
room.
ligation with absorbable suture. Protocol for the successful man-
Bleeding from the sectioned bone end agement of the periosteum is less
is best controlled by pressure. Occa- concretely defined. In instances of di-
sionally, critical in traosseous vessels
Bone Tissue
aphyseal amputation in children, new
will require cauterization or a small The forces passing between prosthe- bone tends to form with periosteal
amount of bone wax. Bone wax sis, residual limb, and the rest of the and endosteal bone overgrowth at the
should be used as infrequently as pos- body are in large part transmitted end of the amputation. Capping the
sible because it remains as foreign tlirough the retained bone in the re- end of a diaphyseal amputation with
material within the surgical site and sidual limb. Therefore, the surgeon osteochondral bone surface (often
can lead to complications. Fortu- must keep this in mind when choos- obtained from the amputation speci-
nately, bone wax is only rarely re- ing the amputation level and shaping men) has been shown to minimize
quired. the bone. Diaphyseal bone should be bony overgrowth. These techniques
Adequate blood supply to the dis- sectioned at the length consistent are addressed in the pediatric chap-
tal tissues and to the wound margins with optimal reconstructive soft- ters.
facilitates proper healing. For appro- tissue closure. Careful management of In its natural state, diaphyseal bone
priate blood supply, the surgeon the severed bone, including careful has an outer covering, or cortex. Thus,
should avoid dissecting the subcuta- contouring and rounding of the sharp it would seem logical to seal the end of
neous tissue, keeping the muscle and cortical bone edges and irregularities, the bone after amputation, and tech-
the muscle-investing fascia with the is essential to pain-free healing. Bone niques have been refined for forming
skin whenever possible. The surgeon transection and shaping should take an osteoperiosteal bone cap over the
should take care to avoid damaging into account the prosthetic devices end of diaphyseal bone. Even without
proximal blood vessels. The skin, or available for that particular level of a surgical osteoperiosteal flap, how-
preferably fasciocu taneous flaps, even amputation. Familiarity with the ever, the end of the bone naturally
when broad based, should be devel- most frequent ~one-related problems heals by formation of callus and fi-
oped with careful attention to blood at the planned amputation level will brous tissue. W11e11 a periosteal cuff is
supply. Preservation of blood supply help the surgeon avoid future prob- available, it may be sutured over the
is especially important in patients lems. For example, in transtibial am- end of the bone, but excessive use of
with vascular disease and diabetes putations, anterior cortical beveling periosteal strips can ca use problems.
mellitus. Careful attention to hemo- to remove the distal corner of the As occasionally seen in traumatic am-
stasis and managing the vascular sup- tibia is one method of proactive man- putations or when the periosteum is
ply to the flaps can make the differ- agement. Removing the distal plantar circumferentially peeled off the bone
ence between healing and failure, corner of the calcaneus in a hindfoot before sectioning, the residual peri-

osteal strips can slowly form irregular cilitate the later definitive amputa- the residua] limb is unsatisfactory for
bone spurs, which can cause painful tion. prosthetic fitting. Revision may also
pressure points. The surgeon should Often a contam inated, open am- be necessar y if the residual limb does
be aware of this potential problem and putation is the result of the original not serve the patient's functional re-
attempt to minimize its occurrence. traumatic injury. Contaminated am- quirements. Thanks to advances in
putations can be treated in a similar prosthetic devices and interfaces,
fashion to other open amputations. limbs that would have been difficult
Wound Closure As always, the first consideration in to fit with prostheses in the past can
The standard protocols for skin clo- performing the amputation is how it now be accommodated reasonably
sure in any other surgery also apply to will eventually be shaped and closed. well. Unfortunately, many amputa-
closing the wound after an amputa- Often in trauma cases, there is an in- tions are still poorly done, leading to
tion. Dead space should be eliminated termediate zone of injured tissue that complications during the healing pro-
and drain systems used when neces- usually needs time to either recover or cess or requiring revision surgery
sary. To close the wound, opposing demarcate, and multiple secondary later. Better education of surgeons,
tissue layers are sewn u11der physio- surgeries may be required before it more research, and additional refine-
logic tension, and care must be taken becomes evident whether the involved ment of surgical technique are the
to ensure the final closure is neither tissue is viable or must be removed. keys to avoiding unnecessary revision
too tight nor too loose. As with all Open amputations are not guillo- amputations.
surgery, careful judgment is necessary tine amputations. They should follow Revision amputation for pain is a
the same surgical principles as other viable option only when the cause of
in the selection of suture material and
amputations, with the same care the pain can be clearly identified. Pain
closure technique, and the surgeon
taken to allow for a healthy, func- problems amenable to surgical treat-
must be aware of the options and dif-
tional residual limb. In past times of ment include redundant tissue, in-
ferences between various techniques.
war, guillotine amputation was used folded skin, painful scars, bone prom-
Many patients have only marginal
to avoid infection. In a guillotine am- inence, bone spurs, heterotopic
blood supply, and the utmost surgical
putation, all the different tissues are
care and technique is required in such ossification, failure of myodesis, dis-
transected a t the same level, much as
cases to maximize the wound healing tinct and identifiable symptomatic
a guillotine blade would sever a limb.
potential. neuromas, and some chronic skin
No flaps arc fashioned, no muscle for
conditions, such as epidermoid cysts
myodesis is retained, and no fasciocu-
and chronic skin breakdown or ulcer-
Staged Amputations tru1eous closure is planned. The post-
ation. Surgery specifically to trea·t
operative plan following guillotine
If primary closure of the wound is phantom pain or pain without clear
amputation is not to perform a sec-
not advisable, amputation should be pathologic cause has not been suc-
ondary closure, but instead to apply
carried out in two or more stages. An cessful.
skin traction, change the dressing
initial amputation may be done to When revising an amputation, the
daily, and administer prolonged
provide adequate drainage of infec- surgeon manages each tissue type
wound care. Distal heaJing with skin
tion. This is the recommended course with the same goals as primary ampu-
traction results in fragile, thin distaJ
fo r a preliminary open ankle disartic- tation but must manage new chal-
coverage with poor durability. Revi-
ulation involving sepsis. with a se- lenges. In revision cases, the muscles
sion is usually required many months
verely infected, nonsalvageable dia- may be scarred and atrophic and
later. The guillotine technique is no
betic foot. Patients presenting with muscle stabilization, while technicaJly
longer recommended. In its War Sur-
such a scenario are frequently febrile possible, tends to be Jess effective with
gery Extremity Course, the US Army
and bacteremic. The initial open am- each successive operation. Nonethe-
now teaches the concepts and tech-
putation helps to control the infec- less, muscle stabilization should al-
niques of open, length-preserving
tion, eliminate the bacteremia, and amputation. Even in instances of ways be considered an essential goal
provide a safer wound environment grave trauma, open amputation with of secondary reconstruction. What-
for a definitive amputation at a later a thoughtful plan for closure is the ever muscle stabilization can be
date. Leaving the bone long and best option. achieved is better than none at all.
avoiding transecting the muscle bel-
lies will minimize the postoperative Postoperative
swelling and edema that often com- Revision Amputation
plicate middiaphyseal open amputa- The genera] principles of primary
Management
tions. When left long, the bone can amputation also apply to revision am- Most surgical procedures are consid-
act as an internal splint, protecting putation. Revision is necessary if the ered complete when the wound is
the remaining soft tissue. This will fa- primary amputation fails to heal or if healed. This is not the case in ampu-

Ch apter 2: General Principles of Amputation Surgery 27
tation surgeries. Every amputee gradual process that cannot be rushed first experiences were documented in
should be considered for functional while the shape an d volume of the comprehensive writings charting both
restoration with an appropriate limb limb are still changing. clean and infected low.er limb ampu-
substitute or prosthesis, and until re- tation procedures. Wilson 9 first de-
habilitation has been completed, the Soft Dressings scribed his experiences with early
process remains unfinished. Although Compressive wound dressings have weight bearing and the treatment of
some amputees may choose not to use long been recognized as essential for amputations of the lower limbs in
a prosthesis, in most cases, an empty controlling swelling, mm1m1Z1ng 1922. He applied the first simple func-
sleeve or trouser leg is an arresting postoperative pain, and promoting tional prosthetic tmits to the rigid
testimony to incomplete postopera- stable limb volume. Even when dressings and allowed his patients to
tive management. Because the resid- nurses, therapists, and other health ambulate with some degree of weight
ual limb must interface with and con- care providers are carefully trained in bearing on the healing amputated
trol the prosthetic device, surgical the protocol and techniques of resid- limb. Wilson's meth ods received little
responsibility ends only when maxi- ual limb wrapping and bandaging, attention until surgeons in France and
mum functional restoration has been these techniques are not always prob- Poland resurrected bis work after
achieved. The surgeon m ust always lem free. Soft dressings are sterile and World War II, when thousands of sol-
remember the ultimate goal: to re- compressible and cover the wound diers were left with unhealed or
place the limb and restore indepen- beneath a layer of elastic bandages. poorly healed amputations. In re-
dence. The bandages support the amputa- sponse to this increase in patient pop-
The primary goals of postoperative tion site under compressive pressure, ulation, Berlemont in France, Weiss in
amputation management include but care must be taken to ensure they Poland, and later Burgess in the
prompt, uncomplicated wound heal- are not so tight as to cause proximal United States revived medical interest
ing, control of edema, control of constriction, or a tourniquet effect. in the use of rigid dressings and the
postoperative pain, prevention of Careful judgment, technical skill, and refining of early postoperative pros-
joint contractures, and rapid rehabili- vigilance are required. Although un- tl1etic techniques. 10 - 12
tation to optimum levels of activity. questionably beneficial to the healing Injured tissues heal best and are
During the first year of prosthetic fit- process, elastic bandages need fre- less painful when they are supported
ting, the residual limb changes shape quent changing and require close and placed at rest. When the injured
and volume, muscles readapt, and the monitoring to maintain the correct limb or amputation site is immobi-
limb "matures." Time and maturation amount of pressure. lized and the appropriate local pres-
are necessary to avoid a mismatch be- The advantages of soft dressing sure and elevation protocols are ap-
tween the shape of the residual limb management include the apparent plied, the inflammatory response and
and the prosthetic socket. ease of application and, because they edema associated with early healing
Postoperative protocols can be de- provide easier access to the wound, are minimized. Immobilization, ap-
signed to actively rehabilitate individ- the surgeon. can inspect the wound plication of gentle distal pressure, and
uals and manage the dramatic site frequently as it heals. Complica- infrequent dressing changes are three
changes in volume and shape that in- tions can arise, however, from poor tenets of good postoperative care. It is
evitably occur. Without patience and wrapping of the residual limb, and it essential that each new generation of
careful planning, a definitive prosthe- is not uncommon for the patient to surgeons be schooled on the impor-
sis may be fabricated too early, only to develop joint contractures. When tance of these tenets. The surgeon's
become incompatible with the resid- used exclusively, soft dressings can curiosity can prompt overly frequent
ual limb when it changes shape. The make muscle conditioning and pain dressing changes and unnecessary
patient is left with a fancy, expensive control more difficult. Even though wound inspection, generaJly doing
prosthesis that is useless, and often some surgeons consider simple soft more harm than good.
must wait to obtain funding for a new dressings outdated in comparison Rigid dressings can be fabricated
prosthesis. This is followed by an- with t he semirigid and rigid postop- from a variety of materials, including
other lengthy process of socket fabri- erative prosthetic techniques avail- conven tional plaster of Paris, elastic
cation, assembly, and alignment. It is able, soft dress~ngs are still preferred plaster of Paris, fiberglass cast mate-
far wiser to use progressive protocols by many surgeons. rial, thermoplastic materials, or other
that allow frequent modification, ad- splinting materials. The dressing is
justment, and replacement of check Rigid Dressings applied at the end of surgery and is
sockets or other temporary devices. For many yea.rs, both open and closed typically changed at intervals of 5 to
These protocols allow for the inevita- amputations have been treated with 14 days. Proper rigid cast protocol re-
ble volume changes without inter- early application of rigid dressings. quires that a therapeutic degree of
rupting rehabilitation until the defin- This technique was first described in1- terminal pressure and a sterile, dry
itive fitting can be made. Fitting is a mediately afte.r World War I, and these wound surface be maintai11ed with no

restrictions to hinder circulation. No The Immediate age can occur, but experience has
proximal constriction should be ap- Postoperative Prosthesis shown that if early weight bearing is
plied to the dressing, and the dressing individualized according to the pa-
The immediate postoperative pros-
must be adequately suspended to tient's skill, understanding, and ability
thetic device can serve as a socket and
maintain distal pressure. Placing a to comply, trouble can be avoided. As
temporary prosthetic Jimb in both always, the surgeon must take into ac-
compressible material, such as closed- upper and lower limb amputations.
cell foam or distal end pads, at the site count the particular patient, the
There are tremendous physical and wound, and the circumstances of the
of surgery helps maintain distal pres- psychological rehabilitative advan-
sure. Suspension is managed initially healing environment.
tages to applying a prosthesis imme-
by molding the cast as it sets and is Finally, in addition to immediate
diately. It minimizes the potentially
later reinforced by devices such as postoperative prosthetic devices fit by
psychologically traumatic period
waist belts or shoulder harnesses. traditional casting techniques, prefab-
when the limb is absent because some
Careful attention to suspension will ricated and custom-fabricated devices
degree of functional restoration can
minimize the likelihood of the cast for immediate fittings are also avail-
begin immediately. The patient's gen-
"falling away," or slipping down and able. The manufacturers of these de-
eral physical and mental state benefit
away from the end of the residual vices emphasize that rehabilitation
from early physical activities. Com-
limb. When a cast falls away, terminal and the return of function is the pri-
parative studies show that, in cases in
edema can develop, often with dire mary goal of treatment.
which postoperative prostheses are
results. At this point in the healing employed immediately, patients have The First Year of Amputee
process, patients should try straight- less pain and mobilize faster. The
leg raises and towel-pull exercises to Care
overall amputee rehabilitation period,
provide intermittent pressure and including hospitalization and the It is essential that the surgeon be fa -
control edema. time allotted for limb maturation, is miliar with the course of amputee
The primary objection to rigid shorter with immediate-fit systems. care and the elaborate nature of the
dressings as a postoperative form of The positive effects of the encourage- prosthetic fitting process. 14 • 15 The
management is that the dressing pro- ment and enthusiasm of the amputa- surgeon must understand that the
hibits frequent inspection of the sur- tion team during this period are very first postoperative year is very differ-
gical site. In most cases this is advan- important, as is the support of family ent from the later years. The ampu-
tageous, however, because a surgical and friends. Positive voices and en- tee's needs regarding components and
site heals best when it is properly sup- couragement are essential in speeding prosthetic technology can change
ported and is undistw·bed and the patient's return to regular activity radically after the limb is mature and
uncontaminated, which a rigid dress- levels. the activity level has increased. For
ing accomplishes. Unusual pain, tem- Although some of the benefits of example, traumatic amputees are typ-
perature elevation, leukocytosis, or the immediate-fit systems have not ically younger patients with more
other evidence of complications, been statistically documented, posi- muscle mass than commonly seen in
however, does require cast removal tive experiences reported worldwide the dysvascular and diabetic amputee
and wound inspection, which are in- support many of the assertions made group. They often experience more
deed somewhat more difficult with a by its advocates. 12 ' 13 Areas of dis- swelling and more dramatic volume
rigid dressing. agreement center on the possibly in- changes in the residual limb. Because
Some surgeons are daunted by the jurious effects of early function, par- the volume of the residual limb is
rigid dressing application process, but ticularly weight bearing and its effect changing dramatically, this can make
although application does require on wotmd healing. Some surgeons the first year of socket fitting particu-
some skill, it requires no more skill feel that early application of a pros- larly difficult.
than the proper application of soft thesis limits access to the surgical site, It is the surgeon's job to help su-
dressings and supportive wraps. thereby preventing inspection and the pervise prosthetic care. When a leg is
Compared with soft dressings, rigid ability to identify infections early. The swollen and not fully mature, even if
dressings have the advantages of im- major concern associated with imme- the patient and the prosthetist are ea-
proved patient comfort and easier diate fitting is potential tissue damage ger to move ahead, the surgeon must
mobility as well as an improved and wound breakdown when exces- resist the urge to prescribe a definitive
wound healing- environment. Regard- sive stresses are applied to the ampu- prosthesis. This intermediate period
less of dressing choice, surgeons must tation site early in the healing process. is essential to the healing process, and
have a firm grasp of modern postop- In general, the application of some acting impatiently will only cause
erative amputation management and distal intermediate pressure reduces later disappointment. One patient
the proper application of postopera- edema and, in many circumstances, had five definitive sockets made dur-
tive dressings. facilitates early healing. Tissue dam- ing the first year after amputation.

Because of these successive failures, socket. Padding techniques can save with a new system that sounds ap-
the insurance provider refused to time, keep the course of rehabilitation pealing at first but is not successful
fund further prosthetic care just when smooth and continuous, and delay for him or her in praqice.
the patient needed it most, and the the hassle of reauthorizing a new
patient was ultimately left with a prosthetic limb until absolutely nec- Choice of Prosthetic
prosthesis that did not fit and could essary. Components
not be used. This is far fro m the ap- The elastomeric liners recently in- Many young traumatic amputees are
propriate standard of prosthetic care, troduced on the prosthetic market adamant about obtaining state-of-
and scenarios like this should be have gained in popularity. Soft and the-art prosthetic components. The
avoided. Similarly, it is a grave disap- pliable, these liners have immecliate prosthesis becomes a part of their
pointment when a patient has limited tactile appeal to the amputee, but body, and their desire for tl1e "finest"
insurance coverage for prosthetic care they can cause skin reactions in some is indeed understandable. However,
and the funds are exhausted too early. patients and are not universally toler- many components may not be opti-
Some patients are left with a pros- ated. Complications reported include mal for the first year of amputee care.
thetic device that looks great and has skin irritation, discomfort from con- Some of the highest-end foot and an-
technologically advanced components striction, and distal traction edema. kle components may be too stiff for
but no longer fits . Patience and finan- One randomized study revealed that
the first 6 to 12 months of ambula-
cial caution will avoid this predica- patients might actually ambulate less
tion. Less technologically advanced
ment. in the elastomeric locking liner sys-
components may make adapting to
Some centers have successfully tems than they do in traditional sys-
the prosthetic device easier.
used reinforced, multiple check- tems. 16 Altllough many protocols
Ideally, a new prosthetic prescrip-
socket prostheses. The patient walks have been advanced for the use of
tion should be generated only after
on each temporary socket for 2 to 8 elastomeric liners and total-contact
the amputee has established a steady
weeks. Ambulatory activity over sev- socket shapes early in the postopera-
symmetric gait, can engage in impact
eral months in a check socket or tem- tive period, these techniques can
activities, and is ready to advance to a
porary socket can help relieve edema. sometimes be more difficult to adjust
higher level of activity. The amputee
Expanded polyethylene foam liners and modify than other systems. No
scientific studies to date have fully as- should be able to maneuver barriers,
are also an excellent option for the
fust socket fitting. Instead of fabricat- sessed the benefits and limitations of manage stairs, and negotiate inclines
ing a brand new socket, the liner can these protocols. I do not typically use and ramps. Typically, this does not
be padded in appropriate locations. elastomeric liners during the first year happen until 9 to 18 months after
These pads compensate for changes in of care because the changes in resid- surger y. Only at this point is a new,
volume in the appropriate location, ual limb volume may be too dramatic more technologically advanced pros-
thereby saving both time and money. to make fittings routinely successful. thesis useful. The old prosthesis can
Typically, when the residual limb Elastomeric liners can be appropriate often be refurbished to become a
in a recent traumatic transtibial am- for select cases in which very fragile spare prosthesis or to be used with
putee loses volume, redness and pain soft tissue or scarring is involved or if water activities.
develop at the end. The first step to traditional systems have failed. In
remedy pain is to increase the ply and these instances, an expandable poly- Conclusions
number of socks to modify fit. The ethylene foam liner can be fabricated
second step is to pad the anteromeclial to fit over the locking liner to provide It is essential that tile thoughtful sur-
and the anterolateral tibial flare re- padcling and adjust to vol ume geon understand the entire course of
gions of the socket or the liner. These changes. the amputation process, from the pre-
regions support the tibia and push Transition between prosthetic sys- operative stage to the final selection of
the distal tibia up and away from the tems can be difficult, and the antici- the perfect prosthesis. As devastating
front of the socket, thus protecting pated benefits are not always realized. as it is for the patient, amputation will
the distal end of the tibia. Skillful Many surgeons or rehabilitation always be a difficult and a complex
padding cru1 maintain a successful fit teams unfortunately transition their process for the surgeon as well. It asks
during periods of volume change patients into new socket shapes or the surgeon to successfully balance ex-
with fewer new socket fabrications. new suspension systems after 12 to 18 isting surgical technique and knowl-
When volume decreases more sub- months without testing the proposed edge, intimate fruniliarity with the en-
stantially, the posterior region of the changes. Again, ambulatory check- tire course of tlle amputee care, and
socket can be padded or the tibial re- socket protocols can allow the patient human understanding of each unique
gions can be padded a second time. It 2 to 8 weeks .to decide if the change is patient. The surgeon capable of mak-
is not uncommon to pad the liner up indeed beneficial. This trial period ing an amputation successful can in-
to four times before fabricating a new keeps the patient from getting "stuck" deed help make the patient whole.

5. Humzah MD, Gilbert PM: Fasciocuta- agement of lower extremity amputees

Acknowledgment n eous blood supply in below-knee using immediate postsurgical prosthe-
I owe much to the wisdom, writings, amputations. J Bone Joint Surg Br 1997; ses. Clin Orthop 1968;57:137-146.
and personal mentorship of Dr. 79:441-443. 13. MooneyV, Harvey JP, McBride E,
Ernest M. Burgess (1911-2000). Much 6. Burgess EM, Romano RL, ZettJ JH, Snelson R: Comparison of postopera-
of this material was updated from Schrock RD Jr: Amputations of the leg tive stump management: Plaster vs
Burgess EM: General principles or for peripheral vascular insufficiency. soft dressings. J Bone Joint Surg Am
amputation surgery, in Atlas of Limb J BoneJointSurgAm 1971;53:874-890. 1971;53:241 -249.
Prosthetics: Surgical and Prosthetic 7. Pedersen HE: Treatment of ischernic 14. Fergason JR, Smith DG: Socket con-
Principles, St. Louis, MO, CV Mosby, gangrene and infection in the foot.
siderations for the patient with a trans-
1981, pp 14-18. Clin Orthop 1960;16:199-202.
tibial amputation. Clin Orthop 1999;
8. Pedersen HE: The problem of the geri- 361:76-84.
atric amputee. Artif Limbs 1968;
LS. Smith DG: Amputations, in Skinner H
References 12(suppl 2) :1 -3.
(ed): Current Diagnosis and Treatment
1. Willingham L: A New Vision for Limb 9. Wilson PD: Early weight-bearing in
in Orthopedics, ed 2. New York, NY,
Loss. SeattJe, WA, Prosthetics Research the treatment of amputations of tJ1e
Lange Medical Books/McGraw Hill,
Study, 2002. lower limbs. J Bone Joint Surg 1922;4:
1999, pp 577-60 1.
2. Burgess EM: General principles of 224-247.
16. Coleman K, Boone D, Smith DG, La-
amputation surgery, in Atlas ofLimb 10. Berlemont M: Ten years of experience
with immediate application of pros- ing L, Mathews D, Czerneicki J: Cross-
Prosthetics: Surgical and Prosthetic Prin-
thetic devices to amputations of the over trial comparing alpha liner with
ciples. St. Louis, MO, CV Mosby, 1981,
lower extremity on the operating ta- pelite liner for trans-tibial p rostheses
pp 14-18.
ble. Prosthet Ort/10t Int 1969;3. using ambulatory activity and ques-
3. Legro MW, Reiber GE, del Aguila M, et
11 . Burgess EM, Romano RL, Zettl JH tionnaire responses, in Transactions of
al: Issues of importance reported by
persons with lower extremity amputa- (eds): The Management of Lower- the Tenth World Congress ofthe Interna-
tions and p rostheses. J Rehabil Res Dev Extremity Amputations: Surgery, Imme- tional Society for Prosthetics and Orthot-
1999;36: 155-163. diate Postsurgical Prosthetic Fitting, ics, July 4, 2001, Glasgow, ScotJand,
Patient Care. Washington, DC, Pros- International Society for Prosthetics
4. Smith DG, Fergason JR: Transtibial
thetic and Sensory Aids Service, 1969. and O r thotics, 2001, p WOS.
amputations. Clin Orthop 1999;361:
108-115. 12. Burgess EM, Romano Rl: The man-

Vascular Disease: Limb Salvage
Versus Amputation
Peter T. McCollum, MCh, FRCSI, FRCSEd
Zahid Raza, MD, FRCSEd, FRCS
Introduction
The most common cause of major In the United Kingdom, 5,000 am- Patients with IC commonly experi-
lower limb amputation in developed putees are referred for prosthetic as- ence pain in the thigh and calf mus-
countries is peripheral vascular dis- sessment each year. There are no data cles when walking or exercising. Leg
ease (PVD), which is often associated regarding the number of patients who pain is usually relieved by rest, but
with diabetes mellitus. Indeed, more undergo amputation in the United pain that persists while the patient is
than 90% of limb amputations are as- Kingdom without being referred for a at rest is generally indicative of severe
sociated with PVD. Other causes of prosthesis. However, based on the es- vascular disease. Severe PVD could
lower limb amputations include timated incidence of critical limb is- result in gangrene and the need for
trauma, tumor, or severe infection. cbemia (CLI) in the general popula- limb amputation. Patients with both
The predominant cause of PVD is tion of 500 patients per million, more PVD and diabetes mellitus have the
atherosclerosis, and its most common than 25,000 cases of CLI occur annu- greatest risk for limb loss. The prog-
manifestation is intermittent claudi- ally in the United Kingdom, and up to nosis is less favorable if the leg is crit-
cation (IC) caused by inadequate ar- 25% of patients (6,250) with CLI will ically ischemic.6 The number of pa-
terial blood supply to the legs. This require a major amputation. This im- tients with limb-threatening ischemia
chapter explores the issues relating to plies that each year, more than l,000 is steadily increasing as a result of the
the choice between amputation and increasing mean age of the general
patients who undergo amputation are
reconstructive surgery for the threat- population and the growing number
not referred for prosthetic assess-
ened limb in patients with end-stage of patients with diabetes meWtus. Pa-
ment. 5
PVD.
The estimated prevalence of PVD
is 3% to 6% of the Western popula-
tion; this increases to 8% in persons TABLE 1 The Fontaine Classification of PVD
older than 55 years. 1•2 IC usually runs Stage Characteristics
a benign course, with less than 6% of I Atherosclerosis without clinical symptoms
patients requiring intervention 1 year II Claudication
after diagnosis.3 Persons with IC have • Claudication at> 200 m
the same life expectancy as a healthy No rest pain
person 10 years older. 4 However, ap- • Claudication at < 200 m
proximately 30% of patients will have No rest pain
died 5 years after onset of IC, and the Ill Rest pain
mortal ity rate increases to 70% by 10 • Ankl e pressure> 50 mm Hg (patient s without diabetes mellitus)
years after onset. Despite this benign Toe pressure< 30 mm Hg (patients with diabetes mellitus)
course, many patients require hospi- • Ankle pressure < 50 mm Hg (patients w ithout diabetes mellitus)
talization and surgery, which has a Toe pressure< 30 mm Hg (patients with diabetes mellitus)
substantial impact on health care re- IV Tissue loss
sources.3 Symptoms worsen with dis- • Ulceration/gangrene with local inf lammation
ease progression, and IC can severely • Ulceration/gangrene with w idespread inflammation
limit physical and social activity.

Limb salvage is neither feasible nor

TABLE 2 Ind ications for Majo r Limb Amputation in PVD desirable for a minority of patients
Incapacitating rest pain who are usually elderly, have pain
Ulceration or gangrene that is extending and resu lts in disability while at rest, and are ill wiili sepsis
Life-threatening sepsis (Table 2). Patients in such circum-
Failed limb salvage operation (nonfunctioning graft/angioplasty) stances often have very advanced
Nonhealing minor amputation PVD and can be described as having
total body failure. Thus their immedi-
ate and short-term prognosis is ex-
tremely guarded. 18•19 If a patient ob-
tients with limb-threatening ischemia who have rest pain but a more favor- viously requires a major lower limb
are often the elderly, who lack social able prognosis with regard to limb amputation, time-consuming and of-
support and are prone to neglect their loss. 11 Another group includes pa-
ten invasive investigations such as an-
health care needs. tients suffering from traumatic injury
giography are not required. A prompt
that causes acute limb ischemia. If
decision to amputate based on clinical
blood flow is insufficient to keep the
Classification of PVD limb perfused, these patients are at
assessment and simple pressure mea-
surements will quickly relieve severe
The first widely used classification of risk of limb loss without immediate
ischemic pain and improve sepsis.
PVD was developed by Fontaine7 and intervention. Limb reperfusion injury
In some patients, it may be appro-
provides a good, albeit simplistic, and the systemic effects of toxic me-
priate to avoid all surgical interven-
classification based on the severity of tabolites are more pronounced in the
tion if the inevitable conclusion is
symptoms. This classification was re- absence of a background of PVD. Pa-
early death. This situation is generally
vised to provide subcategories for patients with otherwise normal vascula-
obvious to the attending physician;
tients with and without diabetes rnel- ture have the greatest risks associated
however, botl, the patient and the pa-
litus (Table 1). The classification of with limb reperfusion injury because
tient's relatives should be involved in
Fontaine is not without problems. Its they will have little if any collateral
making the decision to limit surgical
simplicity suggests that each patient circulation, unlike patients with pre-
intervention. The pain team and pal-
fits neatly into a specific category. The vious underlying PVD, who effec-
liative care physicians provide guid-
fact that a change in Fontaine classifi- tively undergo a process of ischemic
ance for the optima l managemen t of
cation does not necessarily occur only preconditioning.
these patients. Good analgesic sup-
during medical intervention com- port, nursing care, and help with
pounds this problem. Most studies of General planning a dignified death are essen-
medical treatment of patients with
Considerations tial. In such circumstances, the pa-
PVD equate improvement in symp-
tient's relatives can be reassured that
toms, such as healed ischemic ulcer or All patients who are candidates for the care of their loved one involved a
increased claudication distance, with amputation should be assessed by a planned approach to relieve pain and
success of the treatment; therefore, vascular surgeon. 12 ' 13 New techniques make the patient comfortable. In ad-
the use of the Fontaine classification and a more aggressive approach to dition, the patient is not subjected to
can affect the interpretation of clini- limb salvage provide the potential fo r mutilating surgery that would not
cal trials. limb salvage in many patients who are have altered the eventual outcome.
Fontaine stage III or stage N PVD potential candidates for amputation. Clearly, subjecting patients to a pro-
is considered end-stage PVD. Symp- For patients who require amputation, longed hospital stay, inappropriate
toms include leg pain at rest as a re- advances in prosthetics, the establish- surgery, continuing pain, sepsis, and a
sult of CLI. A small but significant ment of centers that specialize in miserable death is tmacceptable.
proportion of patients witl1 advanced treatment of amputees, and improved
CLI has stable symptoms or will even methods of rehabilitation offer a bet-
improve without intervention.8 The ter chance for the functional use of a Psychological
classification of end-stage PVD, how- prosthesis, rather than only using a Aspects of
ever, is complicated by the inclusion wheelchair. 14 - 16 Factors such as
of diabetic patients who have a differ- younger age at amputation, absence
Amputation
ent disease prpcess and prognosis.9 of significant vascular disease in the Health care workers can be so en-
For this reason, the European consen- contralateral limb, and prompt reha- grossed in the physical well-being of
sus document uses a separate cate- bilitation following amputation are patients that the psychological aspects
gory fo r diabetic patients with CLI. 10 associated with a better prognosis for of amputation are overlooked, but
Another category known as subcriti- successful ambulation and overall re- they must remember that the pros-
cal limb ischemia includes patients habilitation.17 pect of undergoing an amputation

Chapter 3: Vascular Disease: Limb Salvage Versus Amputation 33
often comes as a deep shock to the habilitation facilities and prosthetic tation is very unlikely.28 The costs of a
patient and the patient's family. The management. major amputation are significantly
patient should be reassured that the greater than those of a successful arte-
procedure is necessary and that it is rial reconstruction. The costs of an
a positive step toward rehabilitation Financial inpatient hospital stay, physiotherapy,
back into the community. A patient's and nursing care contribute to the
Considerations added expenditures. Admission to a
reaction to the loss of a limb depends
on personality factors and may in- Unfortunately, the financial implica- nursing home during the rehabilita-
clude a period of grief similar to that tions of treating patients with end- tion phase can also contribute to the
following the death of a loved one. stage PVD must be addressed. The overall cost. Provision of a prosthesis,
After lower limb amputation, pa- most cost-effective option for the a wheelchair, or other technical
tients often have poor social support vascular patient is revascularization equipment and modification of the
and multiple medical problems. rather than primary amputation.25 amputee's home can add to the cost. 25
These patients are likely to experience However, this situation is complicated Overall costs. might be reduced if
social isolation, lethargy, pain, and by the costs of multiple failed revas- an efficient outpatient rehabilitation
sleep disturbances. 20 Poor mobility is cularizations and subsequent ampu- program is developed.
a featw-e that exacerbates most of tation compared with tl1e costs of pri-
these symptoms.21 Indeed, patients mary amputation.
who eventually face bilateral amputa- Comparisons of costs of limb sal- Ethical
vage and primary amputation are
tion are unlikely to be ambulatory af-
fraught with difficulties. Nonetheless,
Considerations and
ter the second amputation unless they
are mobilized immediately after the the median cost of successful revascu- Informed Consent
first amputation. 22•23 Any amputation larization in a patient with criteria fa-
vorable for distal bypass is more than The ethical debate of whether to sub-
for lower limb arterial disease should
$10,000 in Great Britain. The inpa- ject a patient to treatment of end-
be performed at the most distal level
tient cost of a primary amputation is stage PVD is paramount. The clini-
possible. The rehabilitation process
$16,000. Repeated failed revascular- cian must address the practical
and psychological support should be-
izations with a subsequent amputa- aspects of intervention. Should limb
gin before or immediately after am-
tion, however, nearly doubles the salvage be attempted when it is likely
putation.
overall costs of treatment.26 Patients to prolong the hospital stay and in-
with preoperative morbidity require crease suffering? What is the true ben-
prolonged hospital care, which is efit of repeated revascularizations
Setting Realistic when there is some doubt regarding
more expensive than the costs associ-
Goals ated with uncomplicated limb revas- limb salvage? In most patients, such
For successful rehabilitation, the cularization of previously healthy pa- decisions will be straightforward. In
health care team must ensure that the tients with CLI. certain patients, however, tl1e clini-
patient's overall needs are met so that Patients sho uld be selected care- cian must ultimately select the treat-
the patient can enjoy life with maxi- fully to exclude those unlikely to have ment option based on the goal of re-
mal independence. The goals set for a successful reconstruction. Impor- ducing patient morbidity by limiting
and by the amputee should be realis- tant determinants of a successful dis- the mental and surgical trauma to the
tic, as unrealistically high expecta- tal bypass include ilie use of an autol- patient. Thus, the decision to limit
tions will lead to disappointment, ogous vein, characteristics of inflow procedlures might be appropriate
negatively affecting the patient's qual- vessels, and the number of patent when there is likely to be a diminish-
ity of life. The health care staff should blood vessels in the calf. 27 Selection of ing return with successive limb sal-
have a balanced and realistic ap- patients is likely to subject unfit pa- vage procedures. Subjecting such pa-
proach to patient rehabilitation and tients to amputation rather than limb tients to the repeated trauma of
be able to determine that the expecta- revascularization. surgery will have devastating conse-
tions of both the patient and family Patients selected for amputation quences on the patient's psyche and
are not exaggerated. are usually older, in poor medical long-term prognosis. Also, the strain
The long-term prognosis for pa- condition, and regarded as inoperable on the patient's family and caregivers
tients with end-stage PVD is generally corppared with those selected to un- must not be overlooked. Such consid-
poor compared with that of the dergo reconstructive smgery. Primary erations are of real importance and
healthy age-matched population. 4 •24 amputation may be the treatment of must be applied to decisions regard-
Adequate patient follow-up is essen- choice in patients who have extensive ing each patient.
tial. In addition, patients and their tissue loss, are elderly with decreased Botl1 the patient and his or her
families should have easy access to re- life expectancy, or in whom rehabili- family should be fully aware of any

anticipated surgical intervention. The Nonsurgical Management sis or occlusion and is inflated to frac-
decision should always be in the pa- of Critical Limb lschemia ture the atheromatous plaque and
tient's best interest. All options of in- recreate a lumen. Often performed
The use of drugs to treat intermittent
tervention and nonintervention must under local anesthesia, PTA has a
claudication and CLI has generated
be explained clearly in terms of the lower morbidity and mortality than
much interest. The goals of pharma-
potential complications and progno- surgical reconstruction. The best re-
cotherapy for patients with CLI in-
sis. If amputation is ultin1ately results of PTA are obtained in larger
clude stabilizing symptoms in the
quired, the patient should be fully in- blood vessels, such as the iliac and
hope of postponing amputation and
formed that all limb salvage options femoral arteries. In general, the long-
relieving rest pain by improving local
term patency is lowest fo r the most
were explored. Patients should under- blood flow and/or the development of
distal lesions that require PTA. Com-
stand that if surgery is not possible or collateral circulation. A number of bining PTA with stenting of stenotic
has failed, amputation and fitting of a drugs have been studied, including
or previously occluded arteries can
prosthesis is a logical and natural pro- anticoagulants, 31 thrombolytics, 32 an-
also be considered. Like PTA, stents
gression. Discussing the procedures tiplatelet agents,33 and other vasoac- work better in more proxinlal lesions.
with a positive attitude · helps the pa- tive agents. 34 The prostacycline ana- Indications to combine stenting with
tient to deal with the amputation. logues are the most promising drugs PTA include recw-rent stenosis fol-
for the treatment of ischemic rest lowing an angioplasty, prevention of
pain. 35•36 Prolonged intravenous infu- recoil of an artery, high risk of embo-
Management sions of prostacycline analogues can lization after PTA, and flow limitation
potentially salvage a small proportion caused by dissection of the artery
The decision to perform either a ma- of limbs from amputation, 35 with a during PTA. PTA with or without
jor amputation or major reconstruc- resultant increase in walking distance stenting generally has an inferior pa-
tive surgery should not be based and diminished rest pain. 36 Most tency rate compared to that of open
solely on clinical parameters or un- studies of prostacycline analogues did surgery.38 Thus, the use of PTA can be
duly influenced by past experience. not select patients using the strict cri- reserved for patients with uncompli-
Vascular surgery has developed as a terion of CLI giving rise to rest pain. 10 cated and discrete lesions or those
full-fledged specialty in many coun- Although lack of consistent criteria unfit for surgery.
tries, and enormous strides have been may have complicated the interpreta-
made in specific areas, such as man- tion of study results, treatment is Subintimal Angioplasty
aging the patient with CLI. In such clearly beneficial in some patients. Subintimal angioplasty is being inves-
patients, distal arterial bypass surgery Prostacycline analogue treatment reg- tigated for the recanalization of
performed at specialized vascular cen- imens are labor intensive and involve longer occlusions. Inadvertently en-
ters and using prosthetic material or infusions that must be administered tering the subintimal space is not an
autologous vein results in satisfactory over a 6-hour period each day for sev- indication to abandon an angioplasty
graft patency and rates of limb sal- eral days. Grad ual increases of dosage procedure, despite previously being a
vage. 29 Patency rates vary consider- are titrated against side effects, which common cause of primary recanaliza-
ably according to the type of conduit, include hypotension, facial flushing, tion failure. A successful outcome
abdominal pain, and headaches. The could be salvaged if the subintimal
length of conduit, state of the inflow
effects of prostacycline analogues have passage dissection was continued un-
vessel, and resistance to· any outflow
been evaluated in several worldwide til reentry into the true lumen beyond
vessel. Factors related to both surgical
multicenter randomized controlled the distal extent of the occlusion39
technique and the patient determine
trials and summarized in a meta- (Figure 1). Subintimal angioplasty
the long-term success of a bypass pro-
analysis that showed some benefit for may offer an alternative to femo rodis-
cedure. In general, the patency rate patients with CLI with an overall re- tal grafting in elderly patients with
for an infrainguinal vein graft can be duction in amputation rate.37 This CLI. However, before the role of sub-
up to 80% at 5 years. In contrast, a benefit is most likely to be seen in pa- intimal angioplasty in clinical practice
synthetic graft will function with a tients with subcritical ischemia. can be established, acceptable patency
patency rate of less than 50% at 5 and limb salvage rates need to be doc-
years. 30 In planning surgical outcome, Percutaneous Transluminal umented by long-term follow-up
it must be recognized that patients Angioplasty studies performed at multiple centers.
with gangrene and rest pain often re- A small number of patients may be
quire a prolonged hospital stay as well suitable fo r percutaneous translumi- Lumbar Sympathectomy
as subsequent rehabilitation after ini- nal angioplasty (PTA). In PTA, with Lumbar sympatl1ectomy has been
tial distal revascularization and/or the use of a guidewire, a balloon cath- used in an attempt to increase the
primary or delayed toe amputation. eter is placed across an arterial steno- blood flow of the lower limb. A

Figure 1 A, Angiography of a patient with CLI showing a saperficial femora l artery occlusion. The patient has a patent popliteal seg-
ment with a two-vessel runoff. B, Recanalization of the occluded segment and reentry into the true lumen were successful following
subintimal angioplasty. There was a complete resolution of rest pain.
orsalis pedis bypass. This 71-year-old patient with diabetes mellitus had gangrene of t he Rgure 2 A popliteal-to-distal ante
s vein has been harvested from the opposite leg and used to bypass from the below-knee toes and also rest pain. The greate
e dead toes were subsequently amputated and healed well with complete resolution of popliteal artery, which was widely
per exposure, with the foot to the left. B, The lateral aspect of the lower exposure, with the rest pain. A. The medial as
the foot to the right.
sympathectomy are uncontrolled, but tensive tissue loss. Long-term studies warmer foot following sym
some have shown an improvement in show that patients who have diabetes tomy is mainly a result of the o
microcirculatory effect. Rates of limb mellitus with no tissue loss and have of nonnutritional arterio
salvage in these studies are similar to an ankle pressure greater than 35 mm shunts. In some patients, a
those described for the natural his- Hg gain the most benefit from this or surgical sympathectomy
tory of CLI.41 technique. 42•43 Overall, only 50% of help relieve ischemic rest pain
At present, the role of sympathec- patients have an initial favorable re- rect effect on pain perceptio
tomy is limited to patients who have sponse to sympathectomy. ways. This effect has also
end-stage vascular disease with no achieved with the use of epid
options for reconstruction. These pa- Vascular Reconstruction nal cord stimulation involving
tients fall into two categories: those The optimal reconstructive vascular mission of low-voltage imp
without tissue loss, and those who procedure varies according to the dis- the epidural space from a pulse
ease rocess. In selected atients, PTA f
Figure 3 A 78-year-old patient underwent in situ saphenous vein femoroposterior tibial bypass grafting. Rest pain was completely re-
lieved. A, The long length of the wounds can be seen in t his medial view of the right leg. B, The completion angiogram shows the vein
graft anastomosed t o th e post erior tibial artery just above the ankle.
of slow virus infection, biodegrada-

tion of grafts, their cumbersome han-
dling characteristics, and expense. For
these reasons, human umbilical veins
are generally unacceptable to most
surgeons. Most surgeons use either
Dacron or expanded polytetrafluoro-
ethylene (PTFE) graft material.
The use of vein cuffs at a distal
transtibial anastomosis improves pri-
mary patency rates 44 (Figure 4) to ap-
proximately 52% at 2 years compared
with approximately 29% without the
Artery Vein cuff
use of the cuff. For distal bypass sur-
gery, a vein cuff results in better pa-
tency rates compared with prosthetic
Figure 4 The Miller vein cuff technique for creating an autologous vein cuff at an in- graft to the crural vessels alone. 45 •46
frageniculate distal anast omosis of a PTFE bypass. (Reproduced with permission from Good salvage rates can be expected
Corson JD, Williamson RCN (eds): Surgery. London, England, Mosby International, 2000.)
from vascular surgeons who regularly
perform distal bypass surgery. Unfor-
is suitable for short (< 6 cm) occlu- can be considered if there is doubt tunately, because this is a specialized
sions. Correction of short lesions by that the patient is fit for a prolonged area, consistently good results tend
PTA will be sufficient to relieve rest major procedure (Figure 2). to occur only in dedicated vascular
pain in some patients. Vascular recon- The choice of material for a bypass units.
structive surgery should be consid- conduit is of paramount importance.
ered for the treatment of longer oc- In most patients, a long saphenous Treatment of Patients With
clusions that are not likely to be vein can be harvested and either re- Infection
treated effectively with PTA. This type versed or used in situ (Figure 3). Vein In patients with PVD, dry gangrene is
of surgery might involve the aorta grafts have superior patency rates a result of reduced arterial inflow or
(aortofemoral, aortoiliac) or the iliac compared to any other form of bypass stasis in the circulation of the limb or
vessels. Vascular reconstruction can material. In patients who have no us- toe. After revascularization, demarca-
also be an infrainguinal procedure, able leg or arm vein, the use of either tion usually is readily observed with-
such as a femoropopliteal or femoro- a prosthetic conduit or human umbil- out evidence of infection in the area of
distal bypass. An extra-anatomic by- ical vein might be considered. The use mummification (Figure 5). Autoam-
pass, such as a femorofemoral cross- of human umbilical veins has become putation of the toe may readily occur
over graft or an ax:illofemoral bypass, problematic because of the possibility without systemic. effects, particularly

where the limb has been revascular- this may be necessary in the absence
ized. Alternatively, simple toe amputa- of immediate specialist resources.
tion can be performed where the limb Of patients admitted with CU,
has adequate blood supply. In con- those with an otherwise normal vas-
trast, "wet" gangrene may be a conse- cular tree are most at risk because
quence of arterial or venous obstruc- there is little if any collateral circula-
tion and often occurs in diabetic tion, unlike patients with previous
patients. Infection and putrefaction underlying PVD. Of all those admit-
are invariably present during this pro- ted with evidence of acute CLI of tl1e
cess. Early revascularization may help legs, approxin1ately 60% to 70% of
to reduce the volume of tissue lost in patients will leave the hospital with an
wet gangrene, although graft infection intact limb. 48 Up to 15% of surviving
is a concern in patients with bypass patients require amputation. 49 Surgi-
surgery, especially with prosthetic cal treatment depends on the specific
grafts. This risk is even more serious circumstances, but general principles
in situations where the patient is pos- include the use of autologous vein as
itive for methicillin-resistant Staphylo- a bypass material if at all possible and
coccus aureus (MRSA) infection. 47 The generous decompression fasciotomies
to reduce the risk of reperfusion in-
decision to amputate or to attempt
limb salvage can be extremely diffi- jury. Selection of the level of amputa-
tion, when necessary, is defined by the
cult, but in the case of life-threatening
available viable tissue and depends Figure 5 Dry gangrene showing demar-
sepsis, primary amputation is usually cation of part of the toes and forefoot.
entirely on clinical assessment with
indicated.
the emphasis on preserving limb
Treatment of Trauma and length. would be beneficial as patients could
Intravenous drug abuse is a prob- be spared additional revision surgery.
Acute Vascular
lem in the medical management of Patients who have a single amputa-
Insufficiency patients with vascular conditions. An tion and are predicted to have
In managing serious limb insult in increasing number of drug abusers adequate healing could be ambulatory
which vascular compromjse is evi- are admitted to the vascular unit fol- immediately following surgery, which
dent, urgent treatment is critical. lowing inadvertent intra-arterial in- is likely to improve both their physi-
Rapid but careful assessment by the jection and microembolization of cal and psychological state.2 1
primary care team and prioritizing various substances. These injuries do
the medical issues are paramount. not seem serious initially, but within a
The patient as a whole should be as- few hours the injected limb can show Selection of Level of
sessed first, followed by evaluation of signs of severe ischemic injmy that is Amputation
the injured limb. The level of priority sometimes irreversible. In such a situ-
with respect to the traumatized limb ation, opening of the diseased artery Three levels of amputation are com-
is generally vessels, nerves, bones, and will show only intraluminal reaction monly used for patients with PVD:
then soft tissues. In reality, surgery is with massive edema causing signifi- ( 1) transfemoral, (2) transtibial, and
often required to repair the bones be- cant hemodynamic stenosis in the ar- (3) transmetatarsal. Unless prior re-
fore vascular reconstruction can be tery. 1n general, treatment consists of vascularization has been performed
attempted in an effort to protect the decompression fasciotomies, intrave- or if the patient has diabetes mellitus,
vessel repair from stress. nous anticoagulant therapy, and pros- amputation should generally be per-
Any patient with a limb with signs tacycline infusions, followed by obser- formed at the transtibial level or
of acute CL! should, if possible, be re- vation. Vascular exploration has a higher. If a more distal level is se-
ferred to a specialist in this field. very limited role. Major amputation is lected,. such as a transmetatarsal am-
Prompt referral of such patients is vi- often the final outcome. This group of putation, and healing occurs, at least
tal. Full and careful evaluation by an patients also has a high rate of infec- one distal vessel must have been suit-
experienced vascular surgeon fol- tion with hepatitis and HIV. ably patent and therefore amenable to
lowed by appropriate investigation a distal revascularization procedure
and subsequent treatment will pro- ratl1er than an amputation.
vide the greatest chance of limb sal-
Prediction of Healing Obviously, the level of the amputa-
vage. These patients should be treated Predicting whether an amputation is tion is important to the patient. Com-
by a specialist, rather than by the oc- likely to heal is challenging. Accurate pared with transfemoral or trans-
casional vascular surgeon, alth ough prediction of amputation healing metatarsal amputation, a transtibial

amputation is likely to allow the pa- Angiography directional velocity meters; the latter is
tient to be more independent, provide Virtually all patients being considered able to differentiate forward from re-
a better cosmetic result, allow lower for amputation should have angiogra- verse movement of blood and to cal-
energy expenditure during ambula- culate blood flow.
phy or some form of imaging, such as
tion, and be associated with lower
arterial duplex or magnetic resonance Ankle Brachia! Pressure
mortality and morbidity. 18 •19
angiography. Any type of angiography
McCollum and associates 50 pro- Index and Segmental
alone has been reported to be a poor
posed that if clinical decisions are Pressures
predictor of wound healing in major
complemented with tests to help de-
lower limb amputation. 55 In contrast, The waveform of the arterial pulse
termine the optimal level of amputa-
a correlation between level of ampu- can be detected in the lower limb us-
tion, a wound healing rate of greater
tation and angiographic scoring has ing a Doppler ultrasonic probe. A cuff
than 90% can be achieved with a ratio
also been observed.56 A patent pro- is placed around the limb and inflated
of transtibial to transfemoral amputa-
funda femoris appears to be of major to determine the systolic pressure by
tions of 3:1. Malone and associates 5 1
importance in the presence of a su- listening to the sound transmitted by
and Moore and associates 52 achieved
perficial femoral artery occlusion and the Doppler probe. When comparing
the proposed healing rates with a
should be ensured before attempting measurements at the thigh, calf, and
transtibial to transfemoral amputa-
a transtibial amputation. 57 An occlu- ankle, a gradient is observed, with the
tion ratio of 3.3:1.
sion of both the profunda femoris greatest amount of pressure at the
An ideal method would be nonin-
and the superficial femoral artery in- thigh and the least amount at the
vasive, quick, have a high degree of
accuracy, and be patient friendly, but dicates a poor prognosis for the heal- most distal end of the limb, usually
this has not been achieved. For this ing of a transtibial amputation. the ankle. The patient's brachia! pres-
reason, many centers advocate the use sure is also taken so that a standard-
Doppler Ultrasound ized ratio can be calculated to allow
of more than one method to increase
the chances of predicting whether a The Doppler ultrasound principle is direct comparisons. This value is ex-
certain level of amputation has heal- used to detect the movement of red pressed as the Ankle Brachia] Pressure
ing potential. No one test has blood cells in vessels in order to assess Index (ABPI).
achieved widespread popularity, and systolic pressure, with the transcuta- Ankle pressures are slightly higher
clinical judgment may p lay the big- neous Doppler flow velocity detector, than arm pressures. When comparing
gest role in amputation decision- the instrument most commonly used lower limb pressures with brachia[
making.53 for this purpose. Moving red cells pressures, a resting ABPI greater than
The ability of a surgeon to deter- cause a backscatter of a transmitted 1.0 is considered normal. An ABPI
mine an amputation level that is sound undergoing a Doppler shift in less than 1.0 suggests stenotic disease.
likely to heal based only on clinical frequency that is directly related to the Patients with IC generally have an
parameters is poor. The absence of velocity of the red blood corpuscles. ABPI in the range of 0.5 to 0.7, and
pulses and capillary bleeding are un- As ultrasound waves contact the skin, patients with rest pain or other severe
satisfactory indicators for healing and they are backscattered as either from ischemic symptoms generally have an
tissue viability.54 Various techniques stationary structures or from moving ABPI ~ 0.3. A pressure less than
have been used to assess skin blood red blood cells. The signals from these 50 mm Hg at the ankle is associated
flow. Care must be taken to ensure components mix to produce interfer- with limb-threatening ischemia. A de-
that the measured flow reflects nutri- ence. The frequency at which this increase of 30 mm Hg or more in pres-
tional blood flow rather than second- terference occurs is the Doppler shift sure from the lower thigh to the ankle
ary flow attributed to the opening of frequency. This shift is directly related suggests a severe stenotic or an occlu-
nonnutritional arteriovenous shunts, to the velocity of red blood cells and sive process. Because measuring seg-
as may occur after lumbar sympath- the cosine of the angle between the di- mental pressures is discontinuous, the
ectomy. rection of blood flow and the ultra- abiHty to measure rapid changes in
sound beam. When the Doppler angle blood flow with this m ethod is lim-
approaches 90° (cosine 90° = O), the ited. The ABPI seldom correlates with
Tests detection of the Doppler shift is jeop- the severity of symptoms. Although it
Tests commonly used in clinical prac- ardized. The ideal Doppler angle is 0° provides good baseline values of arte-
tice are reviewed here. No single ( cosine 0° = 1), but this angle is rarely rial pressure and serves as a guide to
method has 100% sensitivity and achieved. In practice, Doppler angles the extent of ischemia, the ABPI is
specificity. The methods described are between 45° and 60° produce satisfac- useless for selecting amputation level.
often used in combination with other tory results. Two types of continuous- Carter58 evaluated distal systolic
tests to increase the potential predic- wave Doppler machines are available. pressures in patients with and with-
tive value. These ar e the nondirectional and the out diabetes mellitus. In patients with

Chapter 3: Vascular Disease: Limb Salvage Versus Amp utation 39
foot ulceration, the risk of amputa- but it is also used to measu re the ability at the electrode may be com -
tion was greater if the ankle pressure transcutaneous oxygen partial pres- promised in ischemic skin because of
was less than 55 mm Hg. In patients sure of adults with PVD. With this the increased oxygen extraction that
with diabetes, amputation was still a technique, an electrode is placed on occurs in such tissues. ·T hese factors,
strong possibility with higher pres- the patient's skin on the area of inter- combined with a small but potentially
sures because spuriously high pres- est. The electrode should be warmed significant oxygen consumption by
sures can be present in these patients to 44°C to achieve maximal local hy- the electrode itself, may produce erro-
as a result of calcification of the arte- peremia by vasodilation and improve neously low or even zero transcutane-
rial media. Toe pressure measure- the cond itions for oxygen to diffuse to ous oxygen readings in severely is-
ments are a more reliable test in pa- the surface. This warming relaxes the chemic skin, which may actually be
tients in whom calcification of the resistance vessels and abolishes local viable in terms of healing potential. 70
smaller blood vessels of a toe is not autoregulatory mechanisms. 65 A par- Inhalation of 100% oxygen during the
usually a problem.59 More recently, tial pressure greater than 35 mm Hg measurement of TcPo2 can signifi-
pulsed-wave assessment of the toes always predicts wound healing; how- cantly improve the predictive value
has provided information relative to ever, values less than 35 mm Hg do and sensitivity in defining tissue via-
risk of amputation. 60 not always predict failure of tissue bility.7 1 Thus, the inhalation of oxy-
Several investigators have demon- healing. 66 in a patient with severe is- gen helps delineate an interface be-
strated that a transtibial amputation chemic rest pain, it is not uncommon tween viable and nonviable tissues.
to observe a TcPo2 value of O mm Hg
will go on to heal if the popliteal pres-
sure is greater than 70 mm Hg.61 •62
despite a toe pressure greater than Radioisotope Clearance
50 mm Hg. An explanation for this Technique
This finding is of limited use in the
situation is that a very low blood sup-
patient with a popliteal pressure less Freely diffusible radioactive isotopes
ply gives rise to constant, but total,
than 70 mm Hg, however, as healing that have a short half-life can be in-
oxygen extraction at the capillary bed,
is still possible in these patients.6 2 jected int o the skin. The washout rate,
resulting in a TcPo 2 measurement of
Identifying which patien ts are likely often denoted by its half-life, is p ro -
O mm Hg at the skin.67 Patients with
to heal is of utmost importance. One portional to the skin blood flow. This
ischemic limbs often have TcPo 2 val-
problem is that the pressure measured method was initially developed by
ues at the thigh similar to those of
before amputation is not necessarily Kety in 1949.72 After intram uscular
healthy age-matched individ uals, but
reflective of that after amputation. Al- injection of radioactive sodium, the
the values decrease significantly as
though skin blood flow is more im- rate of clearance can be measured,
measurements are taken closer to the
portan t than muscle blood flow after which also correlates with skin blood
ankle,68 which correlates well with
major lower limb amputation, it is flow.
ankle segmental pressures. Healing
difficult to separate skin and muscle The most widely used radioisotope
can potentially occur in areas of
components because the blood flow is xenon Xe 133, which has been
skin with extremely low or O mm Hg
of the whole limb is measured. Physi- shown to be especially well suited to
TcPo2 and, therefore, in situations of
ologic changes after amputation play measurement of blood flow in the
severe ischemia, the TcPo 2 is an in-
a determining role in whether healing
sensitive indicator of the nutritional brain.52 One of the drawbacks of us-
occurs. ing xenon Xe 133 is that it has a high
supply of the skin. Difficulties in cali-
Treadmill stress testing can also be bration of the instrument are often affinity for fat, which leads to an un-
performed in patients in whom the derestimation of skin blood flow. The
encountered and result in large varia-
resting ankle/brachia! pressure is near clearance of this isotope in skin is bi-
tions in TcPo2 values.
normal to determine if exercise causes The initial enth usiasm for transcu- phasic. Despite these disadvantages,
a redistribution of blood that results this radioisotope has been used to se-
taneous oximetry as a major tool for
in a decrease in the ABPI. At best, assessment of limb viability has not lect the amputation level for transtib-
however, this index provides only a been vindicated by clinical studies. ial amputation (TTA) and transfemo-
very crude estimate of the vascular Many problems arise with interpreta- ral amputation (TFA), as well as
status of a patient. tion of the results of this technique, amputations at more distal and prox-
mainly related to the nature of the im al sites.51 ' 52
Transcutaneous Oxygen
electrode.69 In addition, several char- The injection of radioisotopes is
Partial Pressure acteristics of ischemic skin contribute invasive and produces some tissue
Measurement to these difficulties. The skin in these damage. Several measurements often
Transcutaneous oxygen partial pres- patients is likely to be maximally va- have to be made when isolated areas
sure measurement (TcPo 2 ) was ini- sodilated already, and thus local heat- of abnormally high or low skin blood
tially developed to determine the aring provides little or no augmentation flow are encountered.73 Patients also
63 64 of skin blood flow. Also, oxygen avail- are required to lie completely still
terial partial pressure in neonates, •

dming measurements, which can be amples of relevant situations include the patient and the resulting images
difficult for a patient with ischemic monitoring skin flaps and local or over a large smface area. Disadvan-
rest pain. Finally, repeated injections systemic pharmacologic interventions tages include the need for a special-
of radioisotopes are not possible be- that cause changes in skin blood flow. ized room kept at a standard condi-
cause of the potential accumulation A more recently introduced tion and specialized skills to interpret
of relatively large amounts of radia- method of assessing laser Doppler the thermograms. In addition, the
tion, which may cause local and sys- flux is tl1e scanning laser Doppler initial costs of the equipment for
temic cell damage. (Moor Instruments, Devon, England). thermography are high. Maintenance
Other compounds commonly used This device allows readings to be costs also contribute to the overall ex-
include antipyrine labeled with iodine taken without actual skin contact. pense of this technique.
I 125 (4-iodoantipyrine) 74 and thal- Furthermore, it allows a larger area of
limn Tl 201. 75 These isotopes have the body to be scanned. The scanning Fluorometry
different solubilities, redistributions, laser Doppler produces a high-quality Initially described by Lange and
and blood and tissue partition anatomic image from which smaller Boyd,85 this method uses a fiber-optic
coefficients. The radiopharmaceutical areas can be examined in more detail. fluorometer to measure tissue fluores-
4-iodoantipyrine I 125 deserves spe- cence after the intravenous adminis-
cial mention because of its favorable Thermography tration of fluorescein. The movement
pharmacokinetic properties, which T hermography is not only valuable of fluorescein in the bloodstream
include a monoexponential clearance for determining level of amputa- equates to blood flow. Both the uptake
and lower fat solubility than other tion50•79·80 but also is useful in the as- and the elimination of fluorescein can
compounds. sessment of wound healing,81 deep be measured. 86 This method relied
The invasive nature and the risks venous thrombosis, and the evaluation heavily on subjective findings until a
of anaphylaxis, however, remain a of vasoactive drugs.82 The infrared quantitative approach to measuring
problem with the radioisotope wash- thermogram obtains images by detect- fluorescence was developed in 1980.87
out technique. The intradermal injec- ing heat that is radiated from the tis- This method of measurement also
tion is also painful for the patient. In sues. Skin temperature depends not eliminated problems with light trans-
addition, recent legislation has greatly only on blood flow but also is a func- mission caused by pigmented skin . A
increased the cost of production for tion of arterial and venous blood tem- dual-channel fiber-optic light guide is
many of these isotopes, making them perature as well as tissue metabolism.
used; one transmits a blue light to ex-
unaffordable in many hospitals. Any inflammation and variations in
cite the fluorescein in the skin, and the
envirnnmental temperature are likely
Laser Doppler Velocimetry other channel receives the emitted fl uo-
to affect the thermographic image.
rescence, which is measured by a pho-
A laser source providing a monochro- Heat transported to the skin by arte-
tomultiplier tube.
matic light can be used instead of rial perfusion and exchanged at the
Impressive results have been re-
sound waves to measure the Doppler deep dermal plexus as a result of open-
ported by Silverman and associ-
effect. The potential for its use in ing the pre- and postcapillary sphinc-
ates88'89 in predicting amputation
PVD is established.76•77 There appears ters may indicate high blood flow
wow1d healing and selection of level
to be a reasonable correlation be- through arteriovenous anastomosis in
of amputation. Fluorometry has not
tween laser Doppler measurements the skin, rather than a high nutrient
gained widespread acceptance, how-
and radioisotope skin blood flows, 78 blood flow; this result provides a false
ever, because of its failure to reproduce
but results are inconsistent because impression of healing potential.
Thermography is useful to com- meaningful results from other studies,
each method measures different enti-
ties. With the laser Doppler, the plement findings from other tests its invasive methodology, false positive
movement of red blood corpuscles is such as radioisotope tracers,83 as op- results with cellulitic or edematous tis-
recorded at a depth of approximately posed to use as the only test. Ther- sue, and a real, albeit small, risk of
1.5 mm. With a radioisotope, blood mography is useful for the assessment anaphylaxis.
flow is measured at a depth deter- of the viability of skin flaps. A
Light Guide
mined by the depth of the injection. A medial-to-lateral thermal gradient is
major disadvantage of the laser Dop- often present in a lower limb requir- Spectrophotometry
pler is that it only evaluates blood ing a transtibial amputation. This re- Light guide spectrophotometry is a
flow with measurements at individual sult suggests that a medially skewed new method that is noninvasive and
points and thus does not necessarily flap is more likely to undergo healing, easy to perform. A halogen or xenon
represent the same flux value in the as the vascular pedicle is more likely light source is shone on the smface of
rest of the limb. Laser Doppler veloci- to be viable. 83•84 the skin and absorbed by the hemo-
metry is most val uable in assessing T he advantages of thermography globin in the blood. Computer analy-
changing conditions in the skin. Ex- are the lack of physical contact with sis of the reflected light enables mea-

surement of the oxygen saturation of greater than 90%. All too often, an sultants should perform these proce-
the hemoglobin. Spectrophotometers equal number of transtibial and trans- dures.94
with different sensitivities and light femoral amputations are performed Not all studies, however, agree that
guides can be used so that light can be with good primary healing rates, indi- rehabilitation rates and· mobility will
detected at either superficial or deep cating that a disproportionate number improve if an appropriate TTA:TFA
levels of the skin. These are referred to of patients are being subjected to ratio is achieved.95 Partial foot ampu-
as micro- and macro-light guide spec- proximal amputations. There are no tations performed in an attempt to
trophotometers, respectively (Diehl grounds for performing an initial preserve maximum limb function are
GmbH and Co, Ntirnberg, Germany). transfemoral amputation to spare the now more common, especially in dia-
These spectrophotometers are de- patient an additional operation; how- betic patients who are more likely to
signed for in vivo measurements. 90 No ever, the ratio of transtibial to trans- heal after a forefoot amputation in
heating of the epidermis occurs, and femo ral amputations performed var- the absence of concomitant revascu-
contin uous recordings can be made at ies tremendously by institution, laTization. Diabetic vascular disease
one site. The relatively expensive region, and country. This variation is affects the vei:y distal vessels, a factor
equipment and difficulties in the in- likely attributable to surgeons electing that influences healing. Therefore, a
terpretation of measurements limit forefoot amputation in a patient who
to perform a transfemoral amputation
this technique to experimental use un- does not have diabetes mellitus is un-
in borderline patients in an attempt to
likely to heal in the absence of prior
til the system is fully validated. limit residual limb failure. The possi-
revascularization.
Macro- and micro-light guide spec- bility that ill-planned distal amputa-
At present, no established test can
trophotometers produce different re- tions have been performed by inexpe-
completely predict healing after am-
sults for oxygen saturation because of rienced surgeons on tissue that is of
putation. The predictions made by the
differing penetration of the light dubious viability may have contrib-
tests described are purely quantitative
guides and methods of analysis of the uted to the impression that a trans-
and are mainly used to help determine
reflected light beam. Spectrophotome- femoral amputation is necessary and
the level of amputation. An ideal test
try compares favorably with the radio- that distal procedures inevitably re-
would not only accurately predict the
isotope technique of measuring skin quire revision to a more proximal viability of the residual limb but also
blood flow for the selection of level of level. Furthermore, the level of ampu- would be quick, easy to perform, pain-
amputation.91 Encouraging results tation selected is often incorrect, re- less, reproducible, and cost effective.
have been observed for the use of sulting in the conservative option of Regardkss of predictions based on
spectrophotometry for predicting amputating proximally rather than at- laboratory tests, the skill of the sur-
wound healing following amputation tempting a TTA after careful assess- geon is an important determinant of
for critical limb ischemia.92 A clear ad- ment of-the patient. This is especially residual limb failure or success. These
vantage of spectrophotometry is the true in centers that do not have a com- limbs are already deprived of oxygen,
speed at which measurements can be prehensive amputation service and and poor surgical technique can cer-
taken, eliminating the need for a pa- when the level of amputation is based tainly contribute to failure of the am-
tient with a painful limb to keep abso- mainly on clinical judgment. putation wound to heal.
lutely still when recordings are taken. All too often, the need for amputa- Ideally, the patient should be
In addition, the technique is pain free, tion is considered a failure by the sur- transferred to a special unit devoted
noninvasive, and provides immediate gical team and any additional care of exclusively to the care of amputees as
results. these patients is left to the most jun- soon as possible after amputation.
ior of surgeons. As witl1 all surgical Successful ambulation after amputa-
procedures, amputation surgery in-
Summary and tion is best achieved in specialized re-
volves a learning curve for any habilitation centers that are experi-
Conclusions trainee. As one surgeon leaves the enced in caring for amputees.
The optimal level of amputation training program, another inexperi- Typically, up to 80% of patients will
should be based on assessment of limb enced surgeon replaces him or her. be able to ambulate successfully after
viability by specialized techniques and Unless amputations are duectly su- transtibial amputation, but only 30%
clinical judgment.93 An aggressive ap- pervised by an experienced surgeon, of transfemoral amputees will achieve
proach to knee joint preservation in the ratio of transtibial to transfemoral independent mobility. 16 A patient
major lower limb amputation should amputations and the primary healing who undergoes any type of amputa-
be pursued in all patients. More than rates of all amputations will remain tion should start rehabilitation imme-
70% of all major lower limb amputa- poor. Junior trainees should not per- diately postoperatively. Amputations
tions should be at the transtibial level, form amputation procedures as their are predominantly performed in the
and these procedures should be ac- initial training in orthopaedic or vas- elderly, and the overall quality of life
companied by a primary healing rate cular surgery. Senior trainees or con- for these patients is poor unless reha-

bilitation is aggressive. Sadly, many plinary team experienced in the care 12. Lepantalo M, Biancari F, Tukiaioen E:
surgeons fail to appreciate the impor- of amputees. Early involvement of Never amputate without consultation
tance of level selection and appear to such a team allows the amputee the of a vascular surgeon. Diabetes Metab
best chance to live as pain free and as Res Rev 2000;16(suppl l ):S27-S32.
be unaware of the considerable ad-
vantages in retaining the knee joint, independently as possible. Rehabilita- 13. Lindholt JS, Bovling S, Fasting H,
which conserves energy expenditure tion, however, is an ongoing process Henneberg EW: Vascular surgery re-
duces the frequency of lower limb ma-
during ambulation. The more proxi- for all amputees.
jor amputations. Eur I Vase Surg 1994;
mal the level of amputation, the more
8:31-35.
energy that is required during ambu-
lation.96 The amount of energy
References 14. Campbell WB, Ridler BM: Predicting
1. Criqui MH, Fronek A, Barrett-Conner the use of prostheses by vascular am-
needed to walk is a crucial factor for
E, Klauber MR, Gabriel S, Goodman putees. Eur J Vase Endovasc Surg 1996;
elderly patients who already have a 12:342-345.
D: The prevalence of peripheral arte-
low energy reserve. Another aspect of
rial disease in a defined population. 15. Moore TJ, Barron J, Hutchinson F III,
level selection is that an amputee is Circulation 1985;7 1:510-515. Golden C, Ellis C, Humphries D: Pros-
far more likely to make use of a prosthetic usage following major lower
2. Fowkes FG, Housley E, Cawood EH,
thesis if amputation is at the transtib- Macintyre CC, Ruckley CV, Prescott extremity amputation. Clin Orthop
ial level. 97 These patients are also sub- RJ: Edinburgh Artery Study: Preva- l 989;238:219-224.
jected to a higher level of morbidity lence of asymptomatic and symptom- 16. Stewart CP, Jain AS: Dundee revisited:
and mortality because of the nature atic peripheral arterial disease in the 25 years of a total amputee service.
of their systemic vascular disease. 18 general population. Int J Epidemiol ProsthetOrthot Int 1993;17:14-20.
Preservation of the knee joint is gen- 1991 ;20:384-392. 17. Traballesi M, Brunelli S, Pratesi L, Pul-
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is associated with better cosmesis, and the claudicant: A prospective study of nostic factors in rehabilitation of
often allows increased mobility. 1969 claudicants. Eur J Vase Surg 1991 ; above knee amputees for vascular d is-
Most lower limb amputations in 5:131- 133. eases. Disabil Rehabil 1998;20:380-384.
the developed world are performed 4. Bevan EG, Waller PC, Ramsay LE: 18. Stewart CP, Jain AS: Cause of death of
for severe PVD or complications of Pharmacological approaches to the lower limb amputees. Prosthet Orthot
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and fo rmal assessment by the rehabil- 5. Dormandy JA, Ray S: T he fate of the limb amputee survival. Prosthet Orthot
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346.
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cannot be rehabilitated. All patients
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{ed): The Durability of Vascular and amputation. J Bone Joint Surg Am
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Infection: Limb Salvage Vers1:1s
Amputation
John H. Bowker, MD
Introduction
Most limb-threatening infections oc- leaving the skin under the metatarsal number from O to 3 and the level of
cur in the foot, mostly in patients heads with little protective fat pad- perfusion of the foot by a letter from
with long-standing diabetes mellitus. ding. In addition, autonomic neurop- A to D. The combination of mµnber
Among the risk factors for infection athy results in extremely dry skin in and letter provides a concise descrip-
found in tl1is population, sensory which fissures may develop, providing tion of tl1e foot that is useful in plan-
neuropailiy appears to be the most sites of entry for bacteria. ning treatment. For example, a lesion
important. 1•2 Sensory neuropathy is In the absence of normal pain sen- in a grade 1-A foot may be expected
also seen in Hansen's disease (lep- sation, patients commonly exhibit to heal witl, suitable off-loading by a
rosy), alcoholic neuropathy, myelo- marked denial even in regard to open total contact cast or a specially de-
meningocele, syphilis, congenital in- sores, resulting in failure to seek med- signed shoe. A grade 3-A foot, in con-
difference to pain and spinal cord or ical care during the early stages of an trast, will require inpatient wound
peripheral nerve trauma, among oth- infection. Yancey and Brand 3 ascribed debridement and inuavenous antibi-
ers. Because they aTe unable to per- this behavior to a change in body otics. The depth of an ulcer is easily
ceive a correct fit, patients with neur- image/ownership iliat sometimes ac- determined by probing the wound. In
opailiy tend to wear shoes that are too companies ilie loss of pain sensation. the clinic, this can be done with a
tight, ilius inducing ulcer formation In addition, these patients may exhibit sterile applicator, probe, or hemostat.
by diTect pressure and shear forces. a displaced locus of control mani- If bone is contacted with the instru-
These patients may also see no harm fested by an inability to take responsi- ment or is visually exposed in tl,e
in walking wiiliout shoes, at least in bility for care of their feet and/or depths of ilie wound, osteomyelitis
their homes, and iliereby expose medical condition in general. They of- with or without septic arth ritis is usu-
themselves to penetrating wounds ten become quite depressed, especially ally present.6 Radiographs are useful
from various objects left on the floor if they have experienced chronic prob- in determining the extent of bony in-
and other minor environmental lems with ilieir feet, becoming quite volvement. Bone scans are not neces-
trauma. The latter may include hard fearful of amputation as an outcome. sary in ilie usual assessment of most
objects striking ilie foot such as con- All of these basically psychological penetrating lesions.
tainers of food, eiilier in cans or fro- difficulties are likely to result in poor Any wound with clinical signs of
zen, and "stubbing" of bare toes. compliance with a preventive foot care infection should be cultured and tl,e
Swelling and venous congestion of ilie regimen. In diabetic patients, espe- patient initially given intravenous an-
toes can result in loss of tissue. Motor cially those in a state of chronic hyper- tibiotics tl1at cover a wide range of or-
neuropailiy may affect tl1e foot and glycemia, infection is further compli- ganisms, including gram-positive,
toe dorsiflexors and allow a rapid un- cated by decreased phagocytosis and gram-negative, and anaerobic bacte-
controlled descent of t he forefoot fol- chemotaxis of leukocytes. 4 ria.7'8 T he choice of definitive antibi-
lowing heel contact. Trus slapping The approach to management of otics will be determined by culture
gait can result in damage to the skin foot lesions in the diabetk patient is sensitivities. Gentle probing will also
under the metatarsal head area. This greatly simplified by use of the Brod- give a good idea of the extent of any
effect will be aggravated by shifting of sky depili-ischernia foot grading sys- abscess that bas developed in ilie
the metatarsal fat pad distally as the tem5 (Figure 1). This method classi- forefoot. Neuroarthropathic (Char-
toes assume a clawed position, thus fies the depth of the wound by a cot) changes in the foot are com-

(1 11 In) may be useful in diagnosis. 9· 13

In general, however, the presence of
bone infection becomes quite clear
Grade O Grade 2 Grade A Grade C
over a short period of time with the
No break Exposed No lschemla Partial foot
in skin tendons, Joint gangrene aid of serial radiographs and close
clinical observation.
Surgical
Management of
Grade 1 Grade3 Grade B Grade D
Superficial Exposed bone lschemia not Complete Diabetic Foot
gangrene
ulcer and/or
abscess/
gangrenous
Infections
osteomyelitis Patient Evaluation
Prior to embarking on a definitive
Figure 1 The depth-ischemia classification. Each foot is graded with both a number surgical solutio n, the surgeon should
from Oto 3 indicating wound depth and a letter from A to D indicating foot vascularity. determine the patient's potential for
(Reproduced from Bowker JH, Pieifer MA (eds): Levin & O'Neil's The Diabetic Foot, ed 6. wound healing. This includes evalua-
St. Louis, MO, Mosby, 2007, p 277. Reproduced with permission of James W. Brodsky,
tion of blood flow to the foot, nutri-
MD. Copyright © James W. Brodsky, MD.)
tional status, and immunocompe-
tence. Several methods are available
that will give an indication of blood
flow to the distal part of the foot, but
the simplest remains the bedside
Doppler ultrasound test. This can be
done very easily by first applying an
adult-width blood pressure cuff just
above the malleoli and determining
systolic pressure over the dorsalis pe-
dis and posterior tibial arteries. A
child-sized cuff is then placed around
the rnidfoot and pressures are deter-
mined at the level of the metatarsal
necks (Figure 3). If the ischemic index
(foot systolic pressure divided by the
Figure 2 A, Radiograph of the left foot of a severely neuropathic diabetic patient with
Charcot neuroarthropathy. Fracture-dislocation at the midtarsal joint (arrow) has re- brachia! systolic pressure) is greater
sulted in a prominent bony mass. B, Note the large plantar ulcer, which probed to a than or equal to 0.5, foot salvage may
bony mass. MRI or leukocyte scanning may help avoid an erroneous diagnosis of osteo- be feasible, with the caveat that calci-
myelitis. fication of the muscular wall of small
arteries may result in falsely elevated
values, especially in patients with dia-
monly mistaken for acute osteomyeli-
betes. If the ischemic index is less
tis. Infection usually can be excluded than 0.5 and the problem is one of
on clinical examination alone: pa- low-grade infection or distal dry gan-
tients with neuropathic arthropathy grene, the patient should be referred
will not be systemically ill and will ex- to a vascular surgeon regarding the
hibit only moderate local s~in possibility of vascular reconstruction
warmth and discomfort relative to the before limited distal amputations.
bony destruction seen on radio- When Doppler data are unreliable
graphs. On occasion, however, Char- because of severe vessel calcification,
cot deformity may have an overlying transcutaneous oxygen measurements ·
ulcer that penetrates to the bony will give reliable information regard-
Figure 3 Doppler determination of sys-
tolic blood pressure at the level of the
mass, leading to an erroneous diagno- ing local tissue perfusion, especially
metatarsal necks. Note the placement of sis of osteomyelitis (Figure 2). In such when tested during inhalation of
a child-sized blood pressure cuff. cases, a bone biopsy, MRI, or leuko- 100% oxygen. Nutritional status is
cyte scanning with Indium- 111 considered adequate with a serum
American Academy of Orthopaedic Surgeon$

Chap ter 4: Infection: Limb Salvage Versus Amputation 49
albumin level greater than or equal to

3 g/dL, while a total lymphocyte
count of at least l,500/mm 3 is consid-
ered evidence of immunocompe-
tence.14'15
Surgical Approach
The goal of any surgical procedure in
the infected insensate foot is the
prompt removal of all necrotic and
infected tissue while preserving as
much of the forefoot lever as possible.
If an operating room is not immedi-
ately available, an abscess should be
opened widely iJ1 the emergency de-
partment to reduce its internal pres-
sure. This may be accomplished by
using ankle block anesthesia or, in
many cases, no anesthesia at all if the
patient's sensory neuropathy is pro-
Figure 4 A, Right foot of a 52-year-old woman with diabetes mellitus following disartic-
found. Whether the procedure is done ulation of the fourth and f ifth toes and excision of necrotic dorsal skin resulting from
in the emergency department or in wet gangrene. The wound is well covered w ith granulation tissue and ready for split-
the operating room, the surgeon thickness skin grafting. B, Same foot 3 months after grafting. At the time of publication,
should use longitudinal incisions to the graft had tolerated shoe wear for many years. (Reproduced with permission from
Bowker JH: Partial foot amputations and disarticulations. Foot Ankle Clin N Am 1997;2:
preserve as many neural and vascular
153.)
structures as possible. Normal
weight-bearing smfaces such as the
heel pad, lateral portion of the sole, only part of it may be used, depend- 4). To ensure prompt incorporation
and metatarsal head areas should be ing on the extent of the infection. Tis- of split-truckness skjn grafts, depen-
respected. The surgeon should not sues to be removed include grossly in- dent edema as well as direct and shear
compromise a later ablation, such as a fected bone and soft tissue, as well as forces are to be avoided. If a graft has
Syme ankle disarticulation, by unnec- poorly vascularized tissues exposed in been placed across a mobile joint, its
essarily extending a mjdsole incision the area of infection such as cartilage, immobilization in a well-padded cast
into the heel pad or a dorsal incision tendon, joint capsule, and volar plates may be necessary to prevent displace-
proximal to the ankle joint. It is help- of the metatarsophalangeal joints. ment of the graft.
ful, even for an experienced surgeon, The wound is then lightly packed
to first draw one or more possible
with gauze to allow free wicking of Wound Closure in Chronic
surgical approaches on the skin be- Osteomyel itis
infective fluids to the surface.
fore incision to avoid such unin -
Dressing changes two to three In selected chrnnic, nonpurnlent
tended consequences. The surgeon
times daily will remove residual cases of chronic osteomyelitis, follow-
should also begin an open amputa-
wound detritus and encourage granu- ing removal of u1fected and necrotic
tion with a tentative plan for its ulti-
lation tissue growth. Healthy wounds tissue, primary loose closure of the
mate closure, whether secondarily or
can often be secondarily closed 10 to wound should be considered. T he
by wound contraction with or with-
out split-thickness skin grafting. Mul- 14 days postoperatively, thus greatly smgeon should individually assess the
tiple dorsal and plantar incisions may reducing patient morbidity. If doubt feasibility of closed versus open man-
be required to gain full, open drain- exists as to the condition of tl1e agement for each case. The criteria for
age of all abscess pockets. For deep wound, dressing changes should be this method include a wound with
infections, the central plantar spaces, continued twice daily as the wound mirumal or no pus, remaining tissues
described by Grodinsky, 16 can be slowly granulates and contracts over a that ar e not inflamed, and a grossly
opened by a single extensile plantar period of 3 to 6 months. When a clean wound. The methodology origi-
incision as demonstrated by Loeffler healthy granulating wound shows no nally described by Kritter 18 is quite
and Ballard. 17 Although the complete further volume contraction for 2 to 3 simple. A small polyethylene irriga-
exposure begins posterior to the me- weeks, coverage with a split-thickness tion tube is placed in the depths of
dial malleolus and ends between the skin graft is appropriate, particularly the wound and tacked to the skjn. No
first and second metatarsal heads, in non-weight-bearing areas (Figure deep sutures are used, and skin su-

Types of Infections .
Several other infections may result in
lower limb amputation. In Hansen's
disease, infection of peripheral nerves
with Mycobacterium leprae will cause
loss of foot sensation. As in diabetes
mellitus, loss of sensation commonly
leads to ulceration from repetitive mi-
nor trawna. Progressive absorption of
bone and soft tissue aggravated by in-
Figure 5 A, Wet gangrene of t he right great toe in a man w ith diabetes mellitus. Both
phalanges were infected, but some latera l toe skin was salvageable. Forefoot systolic
tractable deep infection following a
pressure was adequate. B, Closure using a lateral toe flap after disarticulation of the skin ulceration may require transtib-
great toe. Note the use of the Kri tter irrigation system, including w idely spaced sutures ial amputation for control (Figure 7) .
to allow egress of irrigation fluid and fixatio n of irrigation catheter to skin. Mycetoma (Madura foot) is a local-
ized, chronic infection caused by No-
cardia and other actinomycetes in
more than 50% of cases, with the re-
mainder cultming many different
fungal species. Mycetoma occms
chiefly in agricultural workers who go
barefoot in the tropics and subtrop-
ics, including the southern United
States. Characteristic "grains" of
clumped organisms exude from mul-
tiple subcutaneous sinuses. If the
Figure 7 Foot of a 53-year-old patient chronic infection is not treated, even-
with Hansen's disease. Note the absorp-
tion of bony and soft-tissue structures of
tual systemic bacterial superinfection
t he forefoot. The hemo~tat is placed in a can be fatal. Progressive destruction
deep sinus leading to a large area of of the pedal skeleton may necessitate
chronic ost eomyelitis in the midfoot and a transtibial amputation (Figure 8).
hindfoot.
Other major infections that some-
times necessitate lower limb amputa-
tion include chronic osteomyelitis
ally occur in a 3- to 5-week period. and life-threatening forms of infec-
tious gangrene such as necrotizing
The alternative is the prolonged mor-
Figure 6 Bulky bandage used to absorb
fasciitis and clostridial myonecrosis
bidity associated with several months
flu id from the Kritte r irrigation system. (gas gangrene).
of healing by secondary intention
The outer of two rolls of bandages is re-
placed every few hours.
while the wow1d is packed open. Bet- Chronic Osteomyelitis
ter cosmesis is also generally achieved
Patients with chronic osteomyelitis
by eliminating the need for skin graft-
usually present with a long-standing
ing of residual defects. The patient draining sinus. The sinus can be
tures are placed at wide intervals. One
should avoid direct weightbearing for probed; radiographs, including a sino-
liter of irrigation fluid is rw1 through
a minimum of 5 to 6 weeks. If a sig- gram, will determine its full extent. To
the wound every 24 hours for a pe-
riod of 3 days. The fluid passes from nificant portion of the forefoot re- obtain a useful preoperative or intra-
the wound between the skin sutures mains, changes in footwear may be operative sample for biopsy, the sur-
and is absorbed by the dressing. The limited to simple fillers attached to an geon must take tissue from the hyper-
outermost wrap is changed every 4 to insole, combined when necessary trophic edge of the lesion, not from
5 hours (Figures 5 and 6). If pus for- with a sole stiffener and rocker sole the central area of tumor necrosis.
mation is nofed on gentle wound on an in-depth shoe. Well-designed When a careful physical examination
compression after discontinuation of shoe wear should provide the partial- reveals palpable popliteal or inguinal
the irrigation, the wound is reopened foot amputee with a stable platform, lymph nodes, a preoperative tumor-
and packed at the bedside. The ad- proper padding of bony prominences, staging evaluation should be done, in -
vantage of this method is that pri- and protection of the foot from exter- cluding CT of the pelvis, abdomen,
mary healing of the wound will usu- nal trauma. and chest. Material from an excisional

Ch apter 4: Infection: Limb Salvage Versus Amputation 51
Figure 8 Right foot of a 54-year-old man

w it h mycetoma. As a political prisoner, he
was forced to work barefoot in soil. Over
a 22-year period, progressive destruction
of the pedal bones occurred.
Figure 9 Right leg of a man with a 46-year history of a draining sinus from chronic os-
biopsy of the sinus and infected bone
teomyelitis of the tibia. Biopsy of t he mass revealed squamous cell carcinoma t hat had
must be carefully examined micro- developed in the sinus. No enlarged inguinal nodes and no local or remote recurrence
scopically for evidence _of squamous was found after short transtibial amputation.
cell carcinoma (Figure 9). If the bi-
opsy is positive, amputation above the
level of tumor and excision of any sus-
picious lymph nodes will be necessary.
Necrotizing Fasciitis
Necrotizing fasciitis is a life-
threatening, rapidly invasive bacterial
infection of the subcutaneous tissue
and fascia. It appears most commonly
as a mixed aerobic and anaerobic in-
fection or may be caused by group A
streptococcus alone. 19 It is seen most
commonly following a traumatic, sur-
gical, or infectious break in the skin
of an immunocompromised older
person ip association with diabetes
mell itus, obesity, end-stage renal dis- Figure 10 Left lower limb of a 68-year-old man with diabetes mellitus fo llowing exten-
sile debri dement of necrotizing fasciitis that fo llowed internal fixation of a hip fracture
ease, cancer chemotherapy, critical 2 weeks earlier. The patient became comatose and died 48 hours after transfemoral am-
limb ischemia, or use of immunosup- putation.
pressive drugs for allografted or-
gans. 20 High mortality rates (20% to
70%) from necrotizing fasciitis are re- come ketotic as well. Elevated muscle often spreads from the limb to the
lated to delay in diagnosis as well as compartment pressures, leading to a trunk. The incision is extended to the
delay in definitive treatment (Figw·e compartment syndrome, may be asso- point where a finger can no longer
10). In its early stages, it is commonly ciated. Compartment pressure mea- readily separate the skin and subcuta-
confused with cellulitis, but necrotiz- surements, therefore, should be neous tissue from the investing fascia.
ing fasciitis does not respond to anti- strongly considered. The s ubcutaneous tissue will often
biotics within the first 48 hours as Once the diagnosis is suspected, have a gelatinous appearance. When
cellulitis should. Palpable crep itus due bedside biopsy and frozen section will the investing fascia is incised, a
to gas formation is present and can be provide a positive diagnosis. This is similar·-appearing material may over-
confirmed by radiographs showing followed promptly by aggressive lie the muscle. All of this material as
gas in the soft tissues. As infection debridement, broad-spectrum antibi- well as the isolated fascia and any gan-
spreads, subcutaneous vessels are oc- otic coverage, and adjunctive hyper- grenous involved skin must be ex-
cluded and dermal gangrene ensues. baric oxygen treatments.2 1 The af- cised. A repeat debridement should be
The patient becomes progressively fected area should be excised widely in done 1 to 2 days later to ensure that all
toxic, and diabetic patients rnay be- an extensile manner, as the infection infected tissue has been excised. Rise-

man and associates 22 reported on a verely toxic patient. A major diagnos- sibility of vessel recanalization or re-
nonrandomized series of patients with tic difference, however, is that gas construction. Once healing is
necrotizing fasciitis. Of 29 patients, 12 gangrene usually develops in a Limb achieved, the patient should be ac-
received debridement and antibiotics with devitalized tissue hours or days tively engaged in a program devoted
alone, and the remaining 17 received after a severe penetrating or crushing to prevention of further lesions by the
hyperbaric oxygen treatments in addi- tramna. Infection spreads rapidly, use of proper footwear, tight control
tion. Despite being much more ill on producing gas and a brown exudate of diabetes, and education in foot care
admission, those who received ad- with progressive toxicity as the myo- with emphasis on assumption of re-
junctive hyperbaric oxygen therapy necrosis extends.25 In most advanced sponsibility for self-cm·e. A similar
had only a 23% mortality rate com- cases, crepitus due to gas formation approach to treatment applies to foot
pared with 66% of those treated with can be readily felt. Early exploration to infections occurring in other condi-
surgery and antibiotics alone. Also of confirm suspicion of gas gangrene is tions associated with loss of protective
interest, the hyperbaric group re- essential. Radiographs may demon- sensation. Necrotizing fasciitis and
quired an average of only 1.2 debride- strate gas in muscle tissue, and the full clostridial myositis/myonecrosis are
ments versus 3.3 for the other co- extent of involvement can be defined two major life- and limb-threatening
hort.22 Based on this and other by MRI and CT imaging. Thorough infections, the control of which de-
studies, the Undersea and Hyperbaric debridement of all necrotic tissue re- pends heavily on thorough, repeated
Medkal Society strongly recommends mains the keystone of treatment. Mas- debridement of infected and necrotic
the routine use of hyperbaric oxygen sive doses of penicillin are specific for soft tissue. Combined with appropri-
treatments as an adjunct to thorough clostridial infection, but a mixed flora ate antibiosis and hyperbaric oxygen
debridement, repeated as needed, and may be present and require additional therapy, debridement can avert ampu-
specific antibiotic therapy.23 Because agents. Tetanus prophylaxis is given, tation if diagnosis is early and treat-
few communities possess or are lo- and polyvalent gangrene antitoxin ment prompt.
cated near a hyperbaric center, the may be necessary. Hyperbaric oxygen
temptation exists to transfer the pa- therapy should be started immediately
following debridement to prevent fur-
Acknowledgment
tient irnmediately. Nonetheless, sup-
portive care provided by a skilled in- ther myonecrosis. Holland and associ- The author wishes to express thanks
ternist remains the third most ates26 reported on 49 patients with to Ms. Patsy Bain for her expert prep-
important clement of good treatment clostridial myonecrosis. In 33 (67%), aration of this manuscript.
in this condition, after surgery and an- this followed closure of wounds: elec-
tibiotics. If these capabilities are tive surgery in 11, and early closure of
trawna wounds in 22. This latter sta-
References
present locally, it would be unwise,
tistic emphasizes the importance of 1. Reiber GE, Vileikyte L, Boyko EJ, et al:
given the rapid course of this infec-
Causal pathways for incident lower
tion, to delay the prompt application delayed closure of wounds resulting
extremity ulcers in patients from two
of these basic measures by transfer of from trauma. The overall survival rate
settings. Diabetes Care 1999;22:
a critically ill patient long distances to was 73.5% . Of 28 patients receiving at 157-162.
a hyperbaric center. Even within cen- least five hyperbaric oxygen treat- 2. Boulton AJM, Malik RA: Diabetic
ters with hyperbaric capabilities, phys- ments, 24 (86%) survived. The ampu- neuropathy. Med Clin North Am 1998;
ically coordinating these treatments in tation rate was 59.4%.26 82:909-929.
a safe manner for such unstable pa- 3. Yancey P, Brand P: The Gift of Pain:
tients may not be possible. Although Why We Hurt and What We Can Do
the limbs of surviving patients are
Summary
About It. Grand Rapids, MI, Zonder-
usually salvaged, their function may The prevention of major lower limb vain Publishing House, 1997.
be compromised by limited joint mo- amputation by salvage of all or most 4. Calvet HM, Yoshikawa TT: lnfection
tion and loss of cutaneous sensation of the foot in patients with foot infec- in diabetes. Infect Dis Clin North Am
from skin grafts and scar, joint con- tions associated with diabetes mellitus 2001;15:407-421.
tractures from associated compart- has become a reality in recent years. 5. Brodsky JW: An improved method for
ment syndrome, and paralysis from Success in this endeavor depends on staging and classification of foot le-
loss of muscle tissue. A customized timely presentation of the patient and sions in diabetic patients, in Bowker
orthosis may be beneficial in restoring control of infection and hyperglyce- JH, Pfeifer MA (eds) : The Diabetic
walking function. 24 mia by a combination of early and Foot, ed 6. St Louis, MO, Mosby-Year
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Gas Gangrene ate antibiotics and insulin. When gan- 6. Grayson JL, Gibbons GW, Balogh K, et
Progressive gas gangrene (clostridial grene or poor healing is related to al: Probing to bone in infected pedal
limb ischemia, a vascular surgeon ulcers: A clinical sign of underlying
myonecrosis) may sometimes be con-
fused with necrotizing fasciitis in a se- should be consulted regarding the fea-

Chapter 4: Infection: Limb Salvage Versus Amputation 53
osteomyelitis in diabetic patients. with diabetic neulopathic arthropathy. surgical disease. Am Surg 2000;66:
JAMA 1995;273:721-723. Diabetes Care 2001;24:2154-2155. 967-971.
7. Lipsky BA: Evidence-based antibiotic 14. Dickhaut SC, DeLee JC, Page CP: Nu- 21. Majeski J, Majeski E: t;recrotizing fasci-
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FEMS Immunol Med Microbiol 1999;26: ing wound healing after amputa- ognition by tissue biopsy and aggres-
267-276. tion.] Bone Joint Surg Am 1984;66:71- sive surgical treatment. South
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Res Rev 2000; 16(suppl 1):S42-S46. eral vascular disease and diabetic in- crotizing fasciitis reduces mortality
9. Wang A, Weinstein D, Greenfield L, et fection: The one-stage versus two- and the need for debridements.
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Magn Reson Imaging 1990;8:805-809. 16:124-127. 23. Ha mpson NB (ed): Necrotizing Soft
10. Maurer AH, Millmond SH, Knight LC, 16. Grodinsky M: A study of fascia! spaces Tissue Infections. Hyperbaric Oxygen
et al: Infection in diabetic neuroarthr- of the feet. Surg Gynecol Obstet 1929; Therapy. Cbmmi ttee Report, Undersea
opathy: Use of indium- 111 labeled 49:739-751. and Hyperbaric Medical Society, Kens-
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Radiology 1986;161 :221-225. cial spaces and a proposed surgical 24. Speers D, Shurr D: Necrotizing fascii-
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12. Beltran J, Campa11i11i DS, Knight C, et 19. Brook I, Frazier EH: Clinical and mi- 26. Ho]land JA, Hill GB, Wolfe WG, et al:
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Diagnosing osteomyelitis in patients Necrotizing soft tissue infections: A

Tumor: Limb Salvage Versus
Amputation
Walid Mnaymneh, MD
H. Thomas Temple, MD
Introduction
Limb salvage for patients with bone well as the presence or absence of from the resulting hematoma. Frozen
and soft-t issue tw11ors is not a new molecular markers expressed by tu- section analysis of tissue removed in
concept; however, its widespread ap- mor cells. the biopsy is necessary to ensure that
plication was made possible by effec- Biopsy errors are common, and adequate material is available for di-
tive multiagent chemotherapy• -s and possible adverse effects on the subse- agnosis. In a multicenter study, Man-
adj uvan t radiation therapy2·9 - 11 as quent surgical treatment may pre- .kin and associates22 reported signifi-
well as improved diagnostic imaging clude successful limb-saving sur- cant p roblems in patient management
and surgical advances in skeletal re- gery.22 The incision for the biopsy caused by inappropriate biopsy tech-
construction. Studies have found local should be longitudinal, not trans- nique in nearly 20% of patients. It
tumor control and overall patient sur- verse, and should be placed in line was found that 8% of the biopsy pro-
vival rates are equivalent whether with the planned incision for the de- cedures altered the prognosis ad-
limb-sparing surgery or amputation is finitive resection so that the entire versely and that 4.5% of the patients
performed. 12-21 Requirements for suc- field of the biopsy can be excised with who might have had a limb-saving
cessful limb-sparing surgery include the resected tum or. Deeper dissection procedure required an amputation as
adequate tumor resection, reconstruc- should avoid intermuscular planes, a result of an iJJ-planned biopsy.
tion of bone and soft-tissue defects, JOmts, and major neurovascular Moreover, errors in diagnosis oc-
and restoration of functio n. If all of structures. Direct bone biopsy should curred twice as often when the biopsy
these goals of limb salvage cannot be be avoided if possible to reduce risk was done in a commu nity hospital
achieved, amputation is necessary. of pathologic fracture, but if such a rather than an oncologic center.
Tumor staging is a process that biopsy is necessary, it should be done Hence, it is recommended that pa-
identifies the tumor type and its ex- through an oval or round cortical tients be transferred to a specialty
tent. It involves a thorough history window. The intraosseous biopsy center before the biopsy, not after.
and physical examination, careful in- site may be plugged with methyl- The surgical ·staging system that
terpretation of radiographic studies, methacrylate cement to prevent has been adopted by the Musculoskel-
and finally a biopsy. A multidisci- spread of tumor cells to soft tissues etal Tumor Society23 - 25 applies to
plinary approach is critical in diag-
nosing and treating sarcomas and,
ideally, should be implemented in an
TABLE 1 Staging of Malignant Tumors
oncology center by a group of indi-
viduals dedicated to these rare can- Stage Grade Compartment Metastases*
cers.22 Treatment is dictated by tumor IA low intracompartmental none
stage, which, in turn, is based on tu- IB low extracompa rtmental none
mor type, size, location, and distant IIA high intracompartmental none
spread. 23 - 25 Prognosis is linked to tu- JIB high extracompartmental none
mor stage, and it is likely that future Ill any any present
staging systems will also account fo r
quantifiable measurements of tumor *Metastases to other organs and lymph nodes; skip metastases in bone
response to adjuvant treatment as

bone as well as soft-tissue tumors. It Surgical Treatment underwent three different procedures:
separates benign tumors into three amputation, arthrodesis, and arthro-
stages: stage l (latent), stage 2 (ac- The ultimate goal of treatment of pa- plasty. A fourth group of healtl1y con-
tive), and stage 3 (aggressive) . Malig- tients with limb sarcomas should be to trol subjects was compared with the
nant tumors are stratified into three maximize the patient's survival by study group patients. The authors
stages based on grade, compartment minimizing the risks of metastasis and found that, for this level of resection,
location, and the presence or absence local recurrence. Thus, the impor- all three groups walked at comparable
of metastases (Table 1). tance of complete tumor resection energy efficiency at three different ve-
Treatment depends on tumor char- cannot be overemphasized. The ad- locities and that energy consumption
acteristics such as type and grade. For vantages of limb salvage versus ampu- was not significantly different than
example, patients with high-grade, tation in the lower limb are the pres- that of the normal control subjects.
chemotherapy-sensitive bone tumors, ervation of a sensate plantigrade foot Patients who underwent amputation
such as osteosarcoma and Ewing's sar- and more energy-efficient ambula- were very active but had difficulty
coma, are treated with adjuvant tion, a factor that becomes increas- walking on w1even surfaces. Patients
chemotherapy,2 •3·5 - 7 whereas patients ingly important with advanced age with artbrodeses had more stable
with chondrosarcomas and low-grade and more. proximal levels of skeletal limbs and performed the most de-
sarcomas of bone require only sur- resection. Other important factors in- manding physical activity but had
gery. A similar strategy is followed in clude the psychological impact of the trouble sitting. Patients with arthro-
soft-tissue tumors: high-grade soft- surgical treatment in terms of the re- plasty led sedentary lives and were the
tissue sarcomas are treated preopera- sultant body image, quality of life, and most protective of the limb but were
tively with either chemotherapy, 13•14 the anticipated function of the limb. the least self-conscious.31 Moreover,
radiation therapy,9- 11 or both2; how- In the upper limb, the main advantage there was no significant difference in
ever, patients with low-grade soft- of limb-sparing surgery is superior psychological functioning among the
tissue sarcomas generally are not function with a sensate hand and op- studied groups.
given chemotherapy, and any require- posable thumb; other advantages are Obviously, further comparative
ment for radiation therapy is based improved cosmesis and self-image. studies that consider the level of am-
on the adequacy of tumor margins. Amputation is associated with putation, age, premorbid functional
Definitive surgical treatment is then fewer surgical complications, shorter status, and response to adjuvant ther-
performed, consisting of resection hospital stays, and better functional apy and that use more sensitive mea-
with limb preservation if feasible, or restoration for patients with tumors surements of gait and function are
amputation. A notable exception is fi- below the knee. Although the initial needed to resolve whether amputation
bromatosis, a benign but aggressive cost of limb salvage is high, the cost of or limb salvage is more appropriate.
disease that can be treated with che- amputation is considerable over the We believe that limb-sparing pro-
motherapy or radiation therapy alone lifetime of an amputee because multi- cedures are superior to more proxi-
· w1"th surgery. 26·27
or ·m con1unct10n
· ple prosthetic devices will be required mal amputations around the hip and
The beneficial effect of preopera- as a result of wear and tear and inevi- shoulder where body image and func-
tive chemotherapy is reflected by the table changes in the size and contour tion are severely affected, energy costs
degree of tumor necrosis seen in his- of the residual limb. of ambulation are higher, and pros-
tologic specimens from the resected Recently, some researchers have ex- thetic fitting is more difficult. Con-
tumor. 5•6 The degree o( necrosis is amined the true advantages of limb- versely, patients with large and high-
significant to the prognosis and is saving procedures over amputations grade tumors below the knee may be
helpful in selecting the postoperative with regard to psychological and better served by amputation and early
chemotherapeutic regimen. An addi- quality-of-life parameters. Sugarbaker prosthetic fitting because in these pa-
tional advantage of preoperative che- and associates 28 and Weddington and tients energy costs are low, prosthetic
motherapy is the possible reduction associates29 found no significant dif- fitting is relatively easy, and function
of tumor size, decrease in perilesional ference between patients who under- is superior to that after most limb-
edema, and containment of the ttunor went amputations and those who had saving procedures.
in a well-defined pseudocapsule. limb-saving procedures. Otis and as-
Sometimes the effects of chemother- sociates30 showed that patients whose
apy on the tumor are dramatic and limbs were salvaged by knee arthro- Indications for
improve the prospect of successful plasty walked at a higher velocity and Limb-Saving
limb salvage and survival. Postopera- a lower net energy expenditui-e than
tive chemotherapy, radiation therapy, patients who had transfemoral ampu-
Procedures
or both are usually administered, de- tations. In contrast, Harris and asso- Conceptually, limb-saving procedures
pending on the type of tumor and the ciates31 compared groups of patients are indicated if all of the following
surgical procedure performed. with distal femoral resections who criteria are deemed attainable: (1 ) an

Chapter 5: Tumor: Limb Salvage Versus Amputation 57
Figure 1 A SO-year-old man presented with a large liposarcoma involving th e quadriceps muscle compartment of the right thigh.
A, Preoperative photograph. B, lntraoperative photograph shows wide resection of t he entire quadriceps compartment. Note the bi·
opsy site that was removed with the specimen and the bare ant erior surface of t he femu r. C, Cut section of the resected specimen.
oncologically adequate resection of fill large dead spaces and occasionally advocate wide resection with adjuvant
the tumor can be achieved; (2) limb require bone, joint, and vascular re- chemotherapy and radiation therapy
reconstruction is technically feasible; construction for extensive tumors for most high-grade tumors. The
and (3) the cosmetic and functional that efface or invade these structures. need for an adequate resection cannot
results are anticipated to be superior be overemphasized because close and
to those of an amputation, with con- positive margins of resection are be-
sideration given to the patient's life-
Tumor Resection lieved to be associated with local re-
style and occupational and recre- Malignant and aggressive benign currence, which in patients with high-
ational demands. The ultimate goal is musculoskeletal tumors should be re- grade malignant bone tumors often is
not merely salvaging the limb but resected according to strict oncologic associated with distant metastases and
constructing a functional and cosmet- surgical principles. The recom- death from disease. 32
ically acceptable limb. If any of these mended procedure for malignant tu- Tumor resectability is determined
goals is not attainable, amputation is mors is either radical or, more fre- by the intraosseous and extraosseous
the preferred option. quently, wide resection of the extent of the tumor as based on ra-
Tumors that lend themselves to tumor.24 Radical resection involves diologic staging studies. Previous bi-
limb-saving procedures include ma- removal of an entire compartment; opsy scars are excised along with the
lignant tumors and some recurrent the entire bone, including the joint underlying tLUnor. The resected bone
aggressive benign tumors (stage 3). above and below; or the entire muscle should include a margin of healthy
Obviously, early diagnosis is impor- compartment, including muscle ori- bone ranging from 3 to 5 cm beyond
tant for successful limb salvage begins and insertions. Wide excisions the intra.osseous tumor extent. For
cause delays in diagnosis lead to in- involve resections outside of the reac- epiphyseaJ or metaphyseal tumors, an
creased tumor size, making limb tive zone or tumor pseudocapsule. It intra-articular resection including the
salvage more difficult. is unclear how much healthy tissue articular surface is necessary. If the
Limb-saving procedLUes are tech- around the tumor must be removed tumor extends into the joint, an
nically more complex than amputa- to constitute an adequate resection. extra-articular resection including the
tions and result in more surgical The type of tissue is also important in whole joint is necessary. In all cases, a
complications and subsequent proce- assessing the adequacy of the margin cuff of soft tissues around the bone is
dures. For patients with bone tumors, of resection. For example, fascia is an also resected.
two major surgical procedures are effective barrier to tumor extension, Displacement or frank invasion of
necessary: one to resect the tumor but fat and muscle fibers are relatively adjacent neurovascular structures is
and another to reconstruct the defect poor barriers (Figure 1). Most ortho- not am absolute contraindication to
and to provide durable soft-tissue paedic oncologists now accept the resection, ie, an indication for ampu-
coverage. Patients with soft-tissue tu- idea that wide margins are adequate tation. If a major vessel is compressed
mors often require muscle transfers to to achieve local disease control and but not directly involved by the tu-

Figure 2 A 15-year-old boy presented with an osteosarcoma of the right distal femur. A, Preoperative radiograph. B, Radiograph
taken 4 months after wide resection of the distal femur and the knee joint followed by tibial rotationplasty shows fixation of the ti-
biofemoral j unction with a plate and screws. C, Appearance of the lower limbs after the rotationplasty. The patient is lying supine with
his right foot pointing backward. D, Another patient wearing a prosthesis designed for rotationplasty, which provides a special socket
for t he foot. The patient is fully functional and ambulates w ithout support.
mor, a careful subadventitial dissec- microscopically to ensure the absence etally immature patients with large
tion is performed to preserve the ves- of tumor. tumors around the knee. It involves
sel. Under certain circumstances, a an extra-articular resection of the
vessel directly invaded or circumfer- knee joint in addition to the lower
entially surrounded by tmnor can be
Skeletal part of tile femur and upper part of
resected with the tumor specimen Reconstruction the tibia. The lower limb is then ro-
and replaced by a reverse vein or syn- tated 180°, and the vessels and nerves
Skeletal reconstruction following tu-
thetic graft. If necessary, major nerves are coiled medially. If tile vessels have
mor resection constitutes the second
invaded by tumor may be resected. In to be removed with the tm11or, anas-
stage of the surgical procedure. The tomosis should be performed. Osteo-
the upper limb, protective sensation
type of reconstruction is determined syn thesis of the distal femoral shaft to
can be restored with nerve grafts, and
preoperatively. However, in most the residual tibial shaft in proximal
motor function can be restored with
appropriate tendon transfers. Sciatic cases where expendable or nonessen- tibial tumors is performed using a
nerve deficits in the lower limb are tial bones are resected, no reconstruc- plate and screws. The ankle joint
debilitating but can be partly com- tion is needed to preserve function. should be placed at or just below the
pensated for by well-fitting orthoses The scapula (except the glenoid por- level of the contralateral knee joint,
and assistive ambulatory devices. tion), clavicle, rib, proximal part of depending on how much growtll re-
The surgeon and pathologist the radius, distal end of the ulna, mains in the normal limb, so that the
should inspect the resected tumor to- metacarpal, phalanx, ischium, pubis, knee joints are at the same level after
gether to identify areas in which tu- patella, fibula, and metatarsal bone skeletal maturity. A special prosthesis
mor appears to be surrounded by can be resected with minimal distur- is constructed to take advantage of
scant healthy soft tissue. These areas bance of function. However, for non- the mobile ankle to restore knee func-
should be inked and examined micro- dispensable or essential bones, skele- tion (Figure 2). The patient and par-
scopically to confirm the absence of tal reconstruction is necessary to ents must be counseled preoperatively
tumor at the margin. If tumor is seen, preserve the limb and its function. because the appearance of the lower
more tissue from the involved area Rotationplasty is an alternative to Jjmb following surgery may be dis-
should be excised and reexan1ined high transfemoral amputat ion in skel- turbing and cause significant psycho-

Chapter 5: Tumor: Limb Salvage Versus Amputat ion 59
logical problems. This is, however, a

durable, oncologically sound, and
highly fw1ctional reconstruction.
The choice of a particular recon-
structive procedure depends on the Figure 3 A 44-year-old wo-
tumor location, the size of the postre- man presented w ith a stage
3 giant cell tumor of the dis-
section defect, anticipated patient tal radi us. The tumor ex-
survival, perioperative use of cyto- tended into the radiocarpa l
toxic drugs, patient lifestyle and occu- joint. A, Preoperative radio-
pation, social and financial consider- graph. B, Radiograph taken
ations, and the surgeon's preference 4 mont hs after wide resec-
tion of the distal rad ius and
and expertise. There are three major
reconstruction using a vascu-
methods of skeletal reconstruction: larized ipsilateral fibular au-
(1) intercalary (segmental) recon- t~graft. The graft healed
struction, (2) arthrodesis, and (3) ar- completely and the patient
throplasty. By and large, the com- resumed her work as a secre-
tary.
monly used constructs for these
reconstructive methods include au-
tografts, allografts, and metal pros- imal third of the tibia or distal part of thus restoring critical motor function
theses. the femur, arthrodesis of the knee is and joint kinematics. Moreover, an
lntercalary reconstruction, which achieved by inserting a long intramed- osteoarticular allograft replaces only
is needed after diaphyseal resection, ulla1·y nail and bridging the resection the involved half (or quarter) of the
uses allografts, autografts ( vascular- defect with a combined construct joint, thus sparing the w1involved
ized and nonvascularized), and, made up of the ipsilateral fibula and normal portions of the joint, whereas
rarely, metallic prostheses. Artbrode- half of the proximal end of the tibia a joint prosthesis requiTes removal of
sis, used to reconstruct the limb after ( to replace a resected distal femur) or the normal uninvolved half of the
extra-articular resection of a joint half of the distal part of the femur (to joint to accommodate the prosthesis.
such as the knee, shoulder, or wrist, replace a resected proximal tibia). Joint preservation in whole or part
also uses allografts, a utografts, or, When successful, this technique re- may result in improved propriocep-
rarely, metal prostheses. Arthroplasty, sults in a stable, pain-free, and function that may translate into improved
used to replace a resected hemijoint tional reconstruction. However, most long-term function. Finally, bone
or whole joint with an articulating patients prefer to have a movable substrate on which future reconstruc-
joint surface such as the knee, hip, rather than a fused knee. The other tions can be based is retained.
shoulder, elbow, or wrist, uses al- surgical technique is the use of a vas- Widespread allograft use is miti-
lografts, metallic prostheses, or cularized free fibular autograft as an gated in part by limited availability,
allograft-prosthesis composites. intercalary graft to reconstruct a dia- potential risk of virally transmitted
Autografts are desirable bone sub- physeal defect.35 The healing potential disease, 40 inconsistent healing, frac-
stitutes because they incorporate is greatly improved over that of an ture,41 and a relatively high risk of
more readily than aJlografts and, once avascular fibulai- allograft because it is infectiion.42 ' 43 Limb-saving recon-
incorporated, do not loosen over time similar to fracture healing. The graft is structive procedures using massive al-
like metal implants. However, their more readily incorporated, heals more lografts are often complex and
use is limited because autografts can- rapidly following fracture, and can re- lengthy procedures with relatively
not replace large bone segments, are model and hypertrophy with time. high rates of complications. Hornicek
associated with donor site morbidity, In contrast to autografts, both al- and associates44 reported 72% .satis-
and offer only limited articular joint lografts and prostheses can replace factory overall results in 840 patients
surfaces (eg, proximal fib ula articular large segments of bones and provide treated at the Massachusetts General
cartilage for distal radius reconstruc- movable joints. Conceptually, al- Hospital. Major complications in-
tion). Vascularized and nonvascular- lografts have certain advantages over cluded fractures in 19%, nonunion in
ized autografts can be used for radio- metal prostheses.36-39 These advan- 18%, infection in 12%, and joint in-
carpal (Figure 3) and tibiotalar tages are related to the biologic nature stability in 5% of the patients. Some
arthrodeses following tumor resec- of the allograft, which allows healing of the patients had more than one
tion. Two other surgical techniques at the graft-host junction by a process complication. Forty-seven percent of
that use large autografts can be ap- of creeping substitution, and the pres- the patients requu·ed additional sur-
plied in selected patients. One is ence of soft-tissue attachments that gery, and most complications oc-
resection-arthrodesis of the knee. 33•34 serve as anchors to which host ten- curred within the first 2 years postop-
Following wide resection of the prox- dons and ligaments can be reattached, eratively. These data are similar to our

using a metal prosthesis. We believe

that the incidence of complications
can be significantly reduced with me-
ticulous surgical techniques, proper
preoperative planning, and good
postoperative management.
The advantages of reconstruction
using metal prostheses include an eas-
ier surgical procedure with fewer com-
plications, especially fracture; more
rapid recovery; and easier rehabilita-
tion in contrast to the long rehabilita-
tion following reconstruction with
an allograft. Improved metallurgy,
rotating-hinge designs, improved ce-
ment technique, and modularity are
factors that have improved outcomes
in patients undergoing reconstruction
with metal prostheses. In the largest
series of patients receiving metal im-
A plants following tumor resection, Un-
win and associates 45 reported survival
Figure 4 A 25-year-old man presented with a large giant cell tumor of the proximal of 32.6% of prostheses in patients with
humerus. A, Preoperative radiograph. B, Radiograph taken 5 years after wide resection
distal femoral replacement and 6.2%
of the proximal humerus and reconstruction using a humeral allograft-prosthesis com-
posite shows that the host-graft junction is completely healed. The patient was doing in patients with proximal femoral re-
well 14 years postoperatively, working as a carpenter. (Reproduced with permission construction at a mean follow-up of
from Mnaymneh W, Malinin T: Massive allografts in surgery of bone tumors. Orthop Clin 120 months. Longer resections re-
North Am 1989;20:455-467.) sulted in worse outcomes in patients
undergoing distal femoral replace-
ment. ln addition, younger patients
had a higher rate of aseptic loosening,
the most common problem in patients
undergoing reconstruction with metal
prostheses. Malawer and Cbou 46 re-
ported survival of prostheses in 83%
of all patients undergoing segmental
reconstruction at 5 years of follow-up
and 67% at 10 years. No differences in
5- and 10-year survival rates were seen
on comparison of sex, age, or diagno-
sis. However, prostl1etic reconstruc-
tion of the proximal part of the tibia
had the worst survival rates. Wirga-
nowicz and associates47 reported that
reconstructions in which custom en-
doprostheses were used to replace tu-
mors failed i11 64 of 278 patients
(23%) with 2-year minimum follow-
Figure 5 A 73-year-old woman presented w ith a chondrosarcoma of the proximal fe- up. For patients with endoprosthetic
mur. A, Preoperative radiograph. 8, Radiograph taken 3 years after wide resection of failures, aseptic loosening and fatigue
the proximal femur and reconstruction with a modular oncologic proximal femoral
prosthesis.
fractme were the most common
causes of failure, occurring in 44% and
16% of patients, respectively.
own. Moreover, several of the compli- adding an autograft to a fractured or Although we generally favor al-
cations of allograft use could be sal- nonunified allograft, replacing a frac- lografts, we prefer to use metal pros-
vaged by subsequent surgery, such as tured allograft with a new aJlograft, or theses in conjunction with intercalary

allografts (allograft-prosthesis com-

posite) in lieu of osteoarticular al-
lografts to replace the proximal femur
and the proximal humerus (Figure 4)
because, in om experience, there has
been an unacceptably high incidence
of fragmentation and collapse of
the allograft ' femoral and humeral
heads. 36•38 We use prostheses in older
patients with high-grade tumors and
relatively short life expectancies (Fig-
me 5) as well as in patients with met-
astatic tumors that cause significant
bone and periarticular destruction.
We also prefer reconstruction with
metal prostheses in patients requiring
resection of the entire bone including
Figure 6 A 61-year-old man presented with a leiomyosarcoma of the distal femur. A,
the joints above and below. Preoperative radiograph. B, Radiograph taken after wide resection of the distal femur
To help solve some of the problems shows that the defect was reconstructed using a modular oncologic rotating -hinge dis-
encountered with customized pros- tal fer'l'loral prosthesis. The patient was doing well 5 years postoperatively. C, A photo-
theses, 48· 50 such as fracture, loosen- graph of the prosthesis used (Manufactured by Howmedica, East Rutherford, NJ).
ing, need of customized implants, im-
proper size, and high cost, new recommended because of the ex- prosthesis composites to reconstruct
modular segmental defect replace- pected significant shortening of the the hip or shoulder joints.
ment prostheses have been developed limb. These expandable prostheses Allograft reconstructions are often
for the proximal and distal ends of can be lengthened periodically to complex and lengthy. Technical fac-
the femur (Figure 6) and proximal gradually keep up with the growth of tors that improve surgical outcomes
parts of the tibia and humerus. This the contralateral limb. include size matching of the graft to
system depends on dual fixation, with the resected segment; rigid fixation of
initial fixation of the solid intramed- the graft-host junction; congruent
ullary stem by methylmethacrylate
Allograft Procedures joint fit; reconstruction of ligaments,
bone cement and long-term fixation We have used four types of allografts tendons, and joint capsule; and ade-
by extracortical bone bridging and in- in procedmes to reconstruct large quate skin and soft-tissue coverage by
growth over the porous shoulder re- skeletal defects in bone tumors. These using, if necessary, local muscle trans-
gion of the segmental prosthesis. 48 •50 are massive osteoarticular allografts, fers, skin grafts, or free flaps. The fol-
The bone bridging around the pros- allograft-prosthesis composites, inter- lowing are examples of allograft re-
thesis is accomplished by applying au- calary allografts, and intercalary construction of the limbs.
togenous iliac grafts over the porous allograft-arthrodesis. The indication
segment. Bone grafting at the for each of these allografts is dictated Scapula
prosthesis-bone junction is believed by the skeletal location and extent of The whole scapula or the functionally
to transmit forces from the body of tumor resection. Sterilely harvested important glenoid and neck portion
the prosthesis through cortical bone osteoarticular allografts that are can be replaced by a scapular allograft
instead of the stem. The grafting also glycerol-treated and frozen are used with satisfactory cosmetic and func -
creates a biologic envelope that theo- most commonly. They are usually tional results. 55
retically impedes the ingress into the used as hemijoints to reconstruct the
bone-cement interface of wear debris knee, wrist, shoulder, and elbow Humerus
that may be partly responsible for joints. Whole-joint allografts have The proxima.l two thirds of the hu-
aseptic loosening. Initial clinical re- proved unsatisfactory because of ar- merus can be successfully replaced by
sults seem to be promising. ticular cartilage degeneration and an osteoarticular allograft. However,
Expandable metal prostheses have bone fragmentation reminiscent of we have observed a relatively high in-
been successfully used in children Charcot (neuropathic) joints. 53,54 In- cidence of late fracture or fragmenta-
with malignant limb tumors. 51 •52 Pre- tercaiary allografts are either frozen tion of the humeral head. 38•39 This
viously, when epiphyseal growth or freeze -dried and are used to recon- has not been a problem with distal
plates of long bones had to be re- struct diaphyseal defects, to achieve humeral allografts. Accordingly, we
moved with the resected tumor in arthrodesis following knee or shoul- now recommend using an allograft-
young children, limb salvage was not der joint resection, or as allograft- prosthesis composite consisting of a

Figure 7 A 23-year-old man presented with a large chondrosarcoma of the ilium. A, Preoperative radiograph. B, Drawing showing the
internal hemipelvectomy resection (shaded area). C, Postoperative radiograph showing t he pelvic reconstruction using a pelvic al-
lograft that included the ilium and acetabulum. Internal fixation of the allograft, using plates and screws for the ilium and pubis as
well as a long lag screw for the ischial host-graft junction. D, Radiograph taken 12 years postoperatively shows complete healing of
the host-graft junction. Note the partial resorption of the graft iliac crest and the narrowing of the hip joint space. The patient am-
bulates with no support. (Reproduced with permission from Mnaymneh VII, Malinin T, Mnaymneh LG, Robinson D: Pelvic allograft: A
case report with a follow UA evaluation of 5.5 years. Clin Orthop 1990;255: 128-132.)
long-stem endoprosthesis combined lar allograft that is fixed to the host volar, thus acting as a buttress against
with an intercalary humeral allograft radius by a dorsally placed compres- volar subluxation of the carpus.
to replace the proximal end of the hu- sion plate. We have observed a late
merus (Figure 4). When evaluation complication of volar subluxation of Pelvis
necessitates resection of the whole the carpus on the allograft radius In selected patients with tumors of
glenohumeral joint or resection of the with progressive degenerative changes the bony pelvis, a partial or complete
deltoid muscle and rotator cuff, we in the radiocarpal articulation. To internal hemipelvectomy can be as ef-
recommend an allograft-arthrodesis prevent this complication, we use a fective as a conventional transpelvic
using a proximal humeral allograft contralateraJ distal radius allograft amputation. However, this procedure
with fusion to the scapula. (right graft in left arm or vice versa) produces significant disability in
and then rotate it 180° on the longitu- terms of loss of hip function and sta-
Radius dinal axis. By rotating the allograft, bility. We favor the use of a massive
The distal end of the radius can be re- the normally long dorsal lip of the ar- pelvic osteoarticular allograft to re-
placed by a size-matched osteoarticu- ticular surface of the radius becomes place the resected hemipelvis. When

Chapter 5: T~or: Limb Salvage Versus Amputation 63
Figure 8 A 16-year-old boy presented w ith an osteosarcoma of the proximal f emur. A, Preoperative radiograph. B, A coronal section
of the resected proximal femur shows the bone destruction by the tumor and the large extraosseous tumor mass. C, Postoperative ra-
diograph after w ide resection of the proximal femur and reconstruction with allograft-prosthesis composite. The long-stem prosthesis
was cemented to the allograft but not to the patient's femur. The host-graft junction was f ixed with a plate and screws. D, Radiograph
taken 2 years postoperatively shows complete healing of the host-graft junction.
Figure 9 A 17-year-old girl presented with a twice-recurrent giant cell tumor of t he distal femur. A, Radiograph shows tumor at sec-
ond recurrence. B, Drawing illustrating the wide resection of t he distal femur and reconstruct ion using a distal femoral osteoarticular
allograft. C, Radiograph taken 6 months postoperatively shows the healing callus over the host-graft junction. D, Radiograph taken 12
years postoperatively shows complete healing of the host-graft j unction and preservation of t he knee j oint space. The patient was still
doing well 22 years postoperatively. (Reproduced with permission from Mnaymneh W, Malinin T, Lackman RD, Homicek FL, Ghandur-
Mnaymneh L: Massive distal femoral osteoarticular allografts after resection of bone tumors. Clin Orthop 1994;303:103-115.)
successful, the pelvic allograft restores resection, a bipolar femoral prosthesis allograft combined with a long-stem
anatomy, stability, function, and limb is used rather than a proximal femo- femoral prosthesis instead of an os-
length 56 (Figure 7). This procedme is ral allogra ft. teoarticular allograft (Figure 8) . This
associated with many complications allograft-prosthesis composite is sta-
including neurovascular injury, hem- Femur ble and provides a good osseous bed
orrhage, infection, hip dislocation, for reattaching tendons.
and fracture. 57•58 If the femoral head In the proximal end of the femur, we In the distal third of the femur, os-
and neck have to be included in the favor the use of a proximal femoral teoarti.cular allografts have often re-

repair are critical. The remnants of

the allograft collateral and cruciate
ligaments are sutured to the corre-
sponding remnants of the patient's
ligaments. In the absence of these at-
tachments, we have reconstructed the
ligaments by using a hemi-Achilles
tendon allograft.37•38 Repair of the
posterior cruciate ligament along
with reconstruction of the anterior
cruciate ligament using a tibial bone
tunnel and over-the-top technique
has resulted in superior stability and
function in our patients.
When the whole knee joint has to
be resected, we have successfully used
distal femoral and proximal tibial
allograft-prosthesis composites with a
rotating hinged-knee prosthesis. For
extra-articular resections in which the
extensor mechanism can be saved,
Figure 10 An 18-year-old man presented with an osteosarcoma of the proximal tibia. however, metal prosthetic reconstruc-
A, Preoperative radiograph. B, Radiograph taken 3 years after wide resection of the
tion is an easier alternative.
proximal tibia and reconstruction using a proximal t ibial osteoarticular allograft. The
host-graft junction has healed completely.
Tibia
Proximal tibial osteoarticular a1-
lografts have been used successfully
(Figure 10). Ligament reconstruction
of the joint is similar to that used with
the distal femoral allograft. The de-
tached patellar tendon is sutured to
the stub of the patellar tendon of the
allograft. To avoid the risk of wound
dehiscence and infection resulting
from scarcity of skin and soft tissues
on the anterior surface of the tibial al-
lograft, it is highly recommended to
transpose the medial or lateral head
Figure 11 A 14-year-old girl pre- of the gastrocnemius muscle anteri-
sented with an adamantinoma
of the tibial diaphysis. A, Preop-
orly to cover the anterior surface of
erative radiograph. B, Radio· the graft. The transposed muscle is
graph taken 4 years after wide then covered with a skin graft. Al-
resection of t he tumorous seg- though patients with proximal tibial
ment of the tibial diaphysis and
allograft reconstruction have a rela-
reconstruction using an interca-
lary tibial allograft that was tively high risk of fracture compared
fixed with a long plate and with patients with metal reconstruc-
screws. Arrows indicate the tion, they have better extensor
completely healed proximal and
function and improved gait mechan-
distal host-graft junctions.
ics. Diaphyseal tumors can be resected
preserving the knee and ankle joints,
sulted in acceptable and durable func- placed. To restore joint stability and and the defect is reconstructed
tion. The entire distal femur (Figure function, size matching of the al- with an intercalary tibial allograft
9) or one femoral condyle can be re- lograft, joint fit, and ligamentous (Figure 11).

Conclusion therapy. J Cancer Res Clin Oncol 1983;

Postoperative
106(suppl):55-67.
Management Despite potential complications, the 8. Weiner MA, Harris MB, Lewis M, et al:
biologic advantages of allografts, in- Neoadjuvant high-dose methotrexate,
Because of the increased risk of infec- cluding the presence of soft-tissue at- cisplatin, and doxorubicin for the
tion, antibiotic treatment is continued tachments and their versatility (either management of patients with nonmet-
postoperatively for about 3 months; alone or in combination with metal astatic osteosarcoma. Cancer Treat Rep
parenteral antibiotics are given peri- prostheses), make them useful for 1986;70: 1431-1432.
operatively and oral antibiotics on limb-salvage procedures following 9. Lindberg RD, Martin RG, RomsdahJ
discharge. There is no scientific evi- wide resections of bone tumors. Re- MM, Barkley HT Jr: Conservative sur-
cent improvements in metallurgy and gery and postoperative radiotherapy
dence, however, that prolonged anti-
in 300 adults with soft-tissue sarco-
biotic coverage in these patients de- prosthetic design have led to in-
mas. Cancer 198 1;47:2391-2397.
creases the risk of infection. creased use of oncologic megapros-
10. Rosenberg SA, Tepper J, Glatstein E, et
Decreased surgery time and blood theses. No single reconstructive pro-
al: The treatment of soft-tissue sarco-
loss, perioperative antibiotics, and ad- cedure is optimal for all situations.
mas of the extremities: Prospective
equate soft-tissue coverage are proba- The orthopaedic on cologist must be randomized evaluations of ( 1) limb-
bly more important in preventing in- familiar with all aspects of limb sal- s paring surgery plus radiation therapy
fection than long-term oral antibiotic vage because the biology and location compared "."ith amputation and (2)
of the tumor, as well as patient de- the role of adjuvant chemotherapy.
therapy. The operating surgeon
sires, age, and comorbid conditions Ann Surg 1982;196:305·315.
should pay close attention to the
must be taken into consideration to 11. Suit HD, Proppe KH, Mankin HJ,
source of the grafts and the methods
ensure optimal outcomes. Wood WC: Preoperative radiation
by which they are harvested and pro- therapy for sarcoma of soft tissue.
cessed. Cancer 1981;47:2269-2274.
In proximal femoral allograft-
References 12. Eckardt JJ, EiJber FR, Dorey FJ, Mirra
1. Gherlinzoni F, Bacci G, P icci P, et al: A JM: The UCLA experience in limb
prosthesis composites, the patient
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walks by using an abduction hip brace
high-grade soft-tissue sarcomas of the Orthopedics 1985;8:612-621.
and crutches for 2 to 3 months, fol- extremities: Preliminary observations. 13. Eilber FR, Mirra JJ, Grant TT, Weisen-
lowed by a crutch or a cane. J Clin Oncol 1986;4:552-558. burger T, Morton DL: Is amputation
For patients with allograft recon- 2. Goodnight JE Jr, BargarWL, Voegeli T, necessary for sarcomas? A seven-year
Blaisdell FW: Limb-sparing surgery experience with limb salvage. Ann Surg
structions about the knee, we immo-
for extremity sarcomas after preopera- 1980; 192:431-438.
bilize the limb in a long leg plaster
tive intraarterial doxorubicin and ra- 14. Eilber FR, Morton DL, Eckardt J,
cast for 8 weeks to allow soft-tissue diation therapy. Am J Surg 1985;150: Grant T, Weisenburger T: Limb salvage
and ligament healing. This is followed 109-113. for skeletal and soft tissue sarcomas:
by protection of the limb in a knee- 3. Jaffe N: Chemotherapy for malignant Multidisciplinary preoperative ther-
ankle-foot orthosis and gradual mo- bone tumors. Orthop Clin North Am apy. Cancer 1984;53:2579-2584.
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orthosis is used until evidence of 4. Link MP, Goorin AM, Miser AW, et al: results of limb spar ing surgery for
union at the allograft-host junction is The effect of adjuvant chemotherapy high grade bone sarcomas of the knee
seen on radiographs. The patient uses on relapse-free survival in patients and shoulder. Orthopedics 1985;8:
with osteosaTcoma of the extremity. 597-607.
crutches to avoid weight bearing on
N Engl! Med 1986;3.14:1600-1606. 16. Rao BN, Champion JE, Pratt CB, et al:
the affected leg un til early signs of
5. Rosen G: Preoperative (neoadjuvant) Limb salvage procedures for children
union are evident.
chemotherapy for osteogenic sarcoma: with osteosarcoma: An alternative to
1n patients with proximal humeral A ten year experience. Orthopedics amputation. J Pediatr Surg 1983;18:
allograft reconstruction, a shoulder 1985;8:659-664. 901-908.
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gradual mobilization of the shoulder
tive adjuvant chemotherapy based on 190-205.
joint. Patients with distal radial al- the response of the primary tu mor to 18. Shiu MH, Turnbull AD, Nori D, Hajdu
lograft reconstruction have the fore- p reoperative chemotherapy. Cancer S, Hilaris B: Cont rol of locally ad-
arm immobilized in a short arm plas- 1982;49:1221-1230. vanced extremity soft tissue sarcomas
ter cast for 6 to 8 weeks, followed by 7. Rosen G, Marcove RC, Huvos AG, et by function-savi ng resection and
protection in a volar splint and grad- al: Primary osteogenic sarcoma: Eight- brachytherapy. Cancer 1984;53:
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19. Sim FH, Beauchamp CP, Chao EY: Predictive factors for local recurrence 44. Hornicek FJ, Gebhardt MC, Sorger JI,
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20. Sim FH, Bowman WE Jr, Wilkins RM, motherapy. Acta Orthop Scand 1998; 45. Unwin PS, Cannon SR, Grimer RJ,
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21. Simon MA, Aschlima11 MA, Thomas tially malignant lesions about the knee for bone tumors of the lower limb.
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Clinical experience with allograft imple for modular segmental defect re-
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57. Bell RS, Davis AM, Wunder JS, Bucon- 1663- 1674.

Trauma: Limb Salvage Versu~
Amputation
Michael T. Archdeacon, MD
Roy Sanders, MD
Introduction
Salvage of the severely traumatized oral amputations. 1 In the American for open fractures with vascular in-
lower limb is a modern concept, pos- Civil War, the mortality rate was 33% jury was negligible.4
sible only since sterile techniques and for transtibial amputations and 54% Advances in all fields of medicine
vascular reconstruction were devel- for transfemoral amputations. In have made salvage of the massively
oped. Before amputation became 1874, von Nussbaum recorded a injured lower limb a reality. Since the
common, an open fracture was a vir- 100% mortality rate for 34 consecu- 1970s, orthopaedic traumatology has
tual death sentence. Until the late 19th tive knee disarticulations. developed into a subspecialty. Highly
century, most patients died even if The development of the germ the- skilled in salvage and reconstruction,
amputation was performed. In 1832, ory, bringing with it hand washing, these surgeons began to view amputa-
Malgaigne reported that the mortality proper sanitation, and nursing virtu- tion of a mangled lower limb as an
rate for amputations performed in ally eliminated mortality from open admission of defeat.5 With even the
the hospital was 52% for major an1- fractures. In World War I, Orr's pro- most complex injury, salvage became
putations and 62% for thigh amputa- tocol for treating open wounds used possible. Guidelines for deciding be-
tions.1 This is not surprising consid- wound extension, cleaning, stable re- tween amputation and salvage did not
ering the methods used. duction of the fracture, and applica- exist, however, nor had the social and
Surgery was conducted on un- tion of plaster with the wound left economk consequences of limb sal-
washed patients in their beds with the vage been addressed.
open.2 As a result, his mortality and
rest of the ward looking on. Before
amputation rates were extremely low.
1846, all surgery was performed with-
out anesthesia.2 Speed was of the es-
Using this technique, Trueta achieved Quality-of-Life and
a 0.6% septic mortality rate in 1,069
sence, and amputations were usually
open fractures in the Spanish Civil
Economic
completed within 3 minutes while Considerations
War. It is interesting to note that these
strong men held the patient down
and casual onlookers put their hands two men simply used the principles of The patient's potential function and
in the wound. Instruments were sim- Pare, who in 1540 advocated irriga- the quality of life need to be consid-
ply wiped clean, often on the sur- tion, debridement, stabilization, and ered in the decision to amputate or
geon's shirt. Surgeons also performed packing of open fractures. 1' 2 salvage the mangled limb. Factors
autopsies and would not wash their As death from wound sepsis virtu- such as donor site morbidity, joint
hands between prosection and ampu- ally disappeared and salvage of the stiffness, neurologic impairment, and
tation. Wotmds were packed with mangled limb became possible, the prolonged rehabilitation times should
dressings made of old bed sheets and next important hurdle was vascular be taken into accowJt. Studies com-
rags. The same pus bucket was used reconstruction. In World War Il, De- paring the long-term functional out-
postoperatively to wash wounds of Bakey and Simeone3 reported an am- comes of amputation and salvage are
every patient on the ward. 1 putation rate of 75% for popliteal ar- ongoing and not yet definitive.
War was even worse. The mortality tery injuries associated with fractures. In addition, the cost and socioeco-
rate for open fractures in the Franco- The Korean War paved the way for nomic impact of limb salvage are in-
Prussian War (1870 to 1871 ) was 50% successful arterial repair. By the Viet- creasing concerns. Between 1992 and
for transtibial and 66% for transfem- nam war, the overall amputation rate 1994, the estimated annual expendi-

ture for the care of musculoskeletal nently disabled. All stated that their or disability. These results demon-
conditions in the United States was relationships with spouses or imme- strate that good outcomes can be
$149.4 billion, and the annual cost for diate family members had become achieved after significant lower limb
fracture care was estimated at approx- strained. Patients with children or trauma, but it is difficult to predict
imately $24 billion.6 Because medical grandchildren stated that they could which patients will not have a good
costs are rising, the predictability and no longer play with them even occa- outcome.
financial burden of a treatment mo- sionally because this required too Pezzin and associates 11 assessed
dality need to be thoroughly investi- much activity. Shopping at the mall long-term outcomes in 146 patients
gated before it can be universally rec- or going out at night was equally dif- with trauma-related amputations. Ap-
ommended. Several studies have ficult, with most patients participat- proximately 25% of the patients re-
attempted to address these particula1· ing in these activities only if abso- ported ongoing problems with the re-
issues. lutely necessary. All stated that they sidual limb, including phantom pain
In 1988, Bondurant and associates 7 were unhappy with the appearance of and wotmds on tJ1e Limb. The number
reported on the cost of limb salvage their limb, their gait, and their shoes. of days in rehabilitation directly cor-
in open grade IIIB and IIIC tibial At the time of final interview, all pa- related with increased vitality, re-
fractures. Of 263 patients, 43 ulti- tients were offered an amputation as a duced bodily pain, and positive voca-
mately underwent amputation. Four- definitive procedure, yet all refused. tional outcomes.
teen patients had a primary amputa- Georgiadis and associates 9 per- In a recent publication, MacKenzie
tion and averaged 22.3 days in the formed a comparnble investigation in and associates 12 compared the demo-
hospital, 1.6 surgical procedures, and 1994. They compared results of limb graphics and socioeconomic charac-
$28,964 in hospital costs. Patients salvage with tJ1ose of early amputa- teristics of patients with high-energy
who underwent attempts at limb sal- tion in 45 patients with open tibial lower limb trnuma with those of the
vage averaged 53.4 days in the hospi- fractures and concomitant soft-tissue general population. More than 70%
tal, 6.9 surgical procedures, and loss, 27 of whom underwent salvage of the trauma patients were white
$53,462 in hospital costs. The authors and 18, early amputation. Amputa- men between the ages of 25 and 40
suggested that early amputation based tion was ultimately required for 5 of years, of whom only 70% had gradu-
on appropriate criteria would im- the 27 limb salvage patients. Limb sal- ated from high school, compared with
prove function, shorten hospitaliza- vage patients also had more compli- 86% nationally. Twenty-five percent
tion, and lessen tJ1e financial burden cations and w1derwent more surgical lived below the federal poverty Jjne,
placed on both the patient and the in- procedures, resulting in longer hospi- and 38% had no health insw-ance. In
stitution. talization, than did patients who un- comparison, 16% of the general pop-
Similarly, in 1990, Sanders and as- derwent early amputation. At 35 ulation lived below the federal pov-
sociates8 evaluated the results of a sal- montJ1s follow-up, the 16 limb salvage erty line, and 20% were uninsured. In
vage protocol in 11 grade IIIB ankle patients available for follow-up were addition, the rate of heavy alcohol
and talus injuries. All patients re- less able to work and had significantly consumption in the patient popula-
quired anterior plating, multiple-level higher hospital charges than early tion was more than twice the national
fusions, free flaps, and bone grafts. All amputation patients. In addition, average.
patients had at least three separate limb salvage patients had more prob- ln another study, MacKenzie and
hospitalizations, with an average of lems with occupational activities, and associates 13 assessed rates of return to
8.2 surgical procedures per patient more of them considered themselves work in 312 patients with severe
(range, 5 to 12) . The to.tal inpatient to be disabled. lower limb trauma. The results were
hospital stay averaged 61.6 days Butcher and associates 10 evaluated 26% at 3 months, 49% at 6 months,
(range, 20 to 107 days), and inpatient disability in 319 patients who had 60% at 9 months, and 72% at 12
costs averaged $62,174 per patient sustained high-energy lower limb months. The characteristics that were
(range, $33,535 to $143,847) . Overall trauma and compared outcomes at 12 most closely associated with return to
hospital cost averaged $1,009 per day. and 30 months. At 30 monilis follow- work were younger age, higher educa-
All injuries healed; the fusion rate and up, 20% of the patients had not re- tion, higher income, a strong support
muscle flap success was 100%; no os- turned to work; 64% of the patients system, and employment in a job iliat
teomyelitis or nonunion occurred; had no disability (as assessed with the was not physically demanding. In ad-
and no patient required subsequent Sickness Impact Profile), 17% had dition, receiving disability income
amputation. N~vertheless, when asked mild disability, 12% had moderate had a strong negative effect on re-
about their functional outcome in de- disability, and 7% had severe disabil- turning to work. These characteristics
tail, all patients stated that the injury ity. The actual physical impairments further demonstrate tJ1at limb salvage
had significantly altered their lifestyle. at 12 months follow-up did not and amputation patients suffer signif-
Five patients returned to a modified change significantly, and this measure icant economic and quality-of-life
job, and the other six became perma- was not a predictor of return to work losses.

Chapter 6: Trauma: Limb Salvage Versus Amputation 71
In this era of managed care, it is

imperative that medical decision- TABLE 1 Treatment Outcomes in Grade Ill Tibial Fractures
making be based on medical evidence Number of
rather than o n financial consider- Number of Number of Number of Secondary
ations alone. Nevertheless, limb sal- Type of Open Fractures I Nonunions/ Infections I Amputations I
Fracture Patients Fractures (%)* Fractures (o/o) t Fractures(%)
vage surgeons need to take into ac-
IIIA 11/10 3/11 (27) 0/11 (O) 0/11 (O)
count the economic burden on the
1118 42/42 15/35 (43) 12/41 (29) 7/42 (17)
patient and the institution in addition
Group 1* 24/24 5/22 (23) 2/24 (8) 2/24 (8)
to quality-of-life issues. Hansen 14 • 15
Group 2* 17/17 10/13 (77) 10/17 (59) 4/17 (24)
and others have noted that when
IIIC 9/9 5/5 (100) 4/7 (57) 7/9 (78)
posttraumatic limb salvage patients
Total 62/61 23/51 (45) 16/59 (27) 14/62 (23)
were candid, they frequently stated
that, although their limbs were saved,
*Fractures that were treated with amputation before 6 mont.hs after injury were
their lives were ruined by the pro- excluded in calculating t he percentages for nonunion.
longed and costly attempts at recon- t Fractures that were treated with amputation within 72 hours after injury were
struction. Hansen has termed this ap- excluded in calculating the percentages for infection.
proach the "triumph of technique *Group 1 defined as early wound coverage within 1 week of injury. Group 2 defined as
over reason." Several authors 1•7 •14 -20 delayed wound coverage after 1 week from injury.
now suggest that early amputation (Reproduced with permission from Caudle RJ, Stern PJ: Severe open fractures of the
tibia. J Bone Joint Surg Am 1987;69:801-807.)
and prosthetic fitting are preferable to
salvage of a questionably functional
lower limb. The goal of this chapter is
to offer information to orthopaedic
surgeons that will help them make ra- TABLE 2 Amputation Rates for High-Energy Lower Limb Trauma
tional decisions when faced with Number of Number of Total
these difficult injuries. Number of Immediate Delayed Amputations
Study Limbs Amputations Amputations (%)
Caudle and Stern 23 9 0 7 7 (78)
Evolution of Limb Lancaster et al24 15 11 2 13 (87)
Salvage Scoring Lange 19 23 5 9 14 (61)
Edwards et al2 5 12 0 1 1 (8)
Indices Helfet et al 18 54 15 6 21 (39)
To determine when amputation is not Bosse et al 26 556 63 86 149 (27)
only justified but also beneficial, an Total 669 95 110 205 (32)
objective tool to predict outcome is
required. In 1976, Gustilo and Ander-
son21 based their prognostic classifi- tibial fractures, type IIIA injuries had cations or functional disability at
cation scheme for open fractures on a low complication rate and type IIIB 1-year follow-up. In contrast, those
wound size. They fo Lmd the type III open fractures had significant com- patients who underwent limb salvage
open fracture to have the worst prog- plications; however, type IIIB open required several operations and had
nosis, with a high rate of infection, fractures with soft-tissue coverage persistent wound or tibia healing
nonunion, and secondary amputa- within 1 week (group 1 in Table 1) problems at 1-year follow-up. The au-
tion. In 1984, Gustilo and associates 22 had fewer complications than those thors suggested that a realistic ap-
subclassified the type lII open frac- covered after 1 week (group 2 in Table praisal of functional outcome needs
ture into type lllA, adequate soft- 1). Type me open tibial fractures had to be made when considering salvage
tissue coverage of a fractured bone disastrous rates: 100% of patients had for limbs with type IIIC injuries be-
despite extensive soft-tissue laceration major complications, and 78% re- cause the overall amputation rate for
or flaps; type IIIB, extensive soft- quired secondary amputation. These these injuries approached 60%. 19•20
tissue injury with periosteal stripping authors began to question the wis- Other investigators 18•19 •23-26 have
and bony exposure usually associated dom of salvage in type IIIB and me cited amputation rates from 8% to as
with massive contamination; and type injuries. high as 87% in high-energy lower
IIIC, an open fracture with an arterial Lange and associates 20 analyzed 23 limb trauma (Table 2). Lange and as-
injury requiring repair. cases of open tibial fractures with sociates20 also consider more than 6
Caudle and Stern 23 found this clas- limb-threatening vascular compro- hours of warm ischemia time and a
sification to be prognostic (Table 1). mise. Fourteen patients (61 %) under- complete disruption of the tibial
In theiT review of 62 ty pe III open went amputation; none had compli- nerve to be an absolute indication for

This injury severity scale considered

TABLE 3 M angled Extremity Syndrome Index (MESI) Points
time from injury, age, preexisting dis-
Injury Severity Score ease, and shock. In this system, a score
0-25 1
of 20 was the dividing line: below 20,
25-50 2 limb salvage could be reliably
>50 3 achieved, and above 20, amputation
Integument rate was 100%. This initial series,
Guillotine 1 however, was limited to only 12 pa-
Crush I Burn 2 tients, fracture type was not identi-
Avulsion I Degloving 3 fied, and an unspecified number of
Nerve primary amputations were included
Contusion (Table 3).
Transection 2 Based on most of the above-
Avulsion 3 mentioned studies, Johansen and as-
Vascular sociates 17 developed a modified ver-
Artery sion of the MESI they termed the
Tra nsected Mangled Extremity Severity Score
Throm bosed 2 (MESS) to predict amputation (Table
Avulsed 3 4). This scoring system was used only
Vein in documented type IIIC open tibial
Bone fractures; first retrospectively in 26
Simple fracture 1 cases and then prospectively in 26
Segmental fracture 2 more. The score was assigned after the
Segmental-Comminuted fractu re 3 salvage versus amputation decision
Segmental-Comminuted fractu re with 4 had been made. In both groups there
bone loss < 6 cm
cin-nihr'..ll}t rliff,.:.rpn ,..P ln thP
_ _ _ __ ...::__ _ _ __:__:_---,---=-=--=-·_. ..
_ _- _- ·_· _, ._.._- _- _··-
't.\1"l-.C..
--,,----,,.,,-,.--.---
"l
··_ -_ _ ume h·o m mmrv, age, oreeXlS t u"
1
n
the potential risks and benefits of sal-

TABLE 4 The M angled Extremity Severity Score (M ESS) Points vage and amputation in each case.
Skeletal I Soft-Tissue Injury
Low-energy Stab wounds, simple closed fractures,
small-caliber gunshot wounds
Managing the
Medium-energy Open/segmental fractures, dislocations, 2 Salvaged Limb
moderate crush injuries
High-energy Shotgun blast (close range), 3 When the decision to salvage a man-
high-velocity gunshot wounds gled lower limb is made, the first step
Massive crush Logging, railroad, oil rig accidents 4 is to evaluate the wound and then
Shock sterilely cover it in the emergency de-
Normotensive Blood pressure stable in the fie ld and 0 partment. Tetanus prophylaxis should
hemodynamics the operating room be performed, prophylactic systemic
Transient ly hypotensive Blood pressure unstable in t he field but antibiotics s)1ou1d be administered
responsive to intravenous fluids
immediately, and the wound should
Prolonged hypot ension Systolic pressure < 90 mm Hg in the 2
field; responsive to intravenous f luids not be exposed again until the patient
only in t he operating room is in the operating room. For type III
lschemia open fractures in the mangled lower
None A pulsatile limb, no signs of ischemia 0 limb, a first generation cephalosporin
M ild Dim inished pulse, no signs of ischemia is used. We advocate cephazolin 1 to
Moderate No Doppler pulse, sluggish refill, 2 2 g every 8 hours. An aminoglycoside
paresthesias, diminished motor
activity such as gentamycin 2 to 6 mg/kg in
Advanced Pulseless, cool, paralyzed, no refi ll 3 divided daily doses should be given
Age as well. For massively contaminated
< 30 years 1 wounds or wounds at risk of clostrid-
30-50 years 2 ial infection, aqueous penicilEn 4 to
> 50 years 3 6 million U every 4 to 6 hours should
MESS Score Sum of also be given. Vascular surgery con-
points sultation should be obtained when
appropriate and the patient taken to
the operating room as quickly as
possible. Depending on the recom-
outcome. This emphasizes the diffi- injuries. Injuries requiring local flap mendation of the consulting vascular
culty of developing reliable limb sal- coverage or free tissue transport were surgeon, angiography is done preop-
vage scoring indices. Because no in- classified as type IIIB injuries. Only eratively or intraoperatively.
dex has been validated, a multicenter injuries requiring a vascular proce- The next step in the management
study,26 the Lower Extremity Assess- dure for limb viability were catego- of these injuries is proper surgical
ment Project (LEAP), was begun to rized as type IIIC injuries. debridement and lavage. In no other
attempt to develop reliable criteria for Analysis of the prospectively col- injury is complete and meticulous
salvage and amputation. lected data for 556 high-energy lower debridement so important. All ne-
LEAP, funded by the National In- limb injuries revealed that none of crotic and contaminated tissue must
stitutes of Health (NIH), was begun the previously developed scoring sys-
in 1994 to evaluate severe lower limb be excised. Elliptical excision of the
tems (MESS, PSI, LSI, NISSSA, and necrotic wound edges is performed.
injuries at eight level l trauma cen-
HFS-97) was clinically valid. In addi- This is followed by wound extension,
ters. Clarification of the open fracture
tion, although low scores were highly both proximally and distally, to ex-
classification systems is critical to as-
sess the clinical utility of limb salvage specific for performing limb salvage, pose and identify all deep devitalized
scoring systems. The LEAP authors their sensitivity was low. Currently, no tissues. With a mangled limb, exten-
modified the classification system of limb salvage index has been statisti- sive injury to the surrounding muscle
Gustilo 21 ' 22•33 so that final grading of cally confirmed to be reliable in the envelope is inevitable, so the surgeon
open fractures was determined at the evalµation and treatment of patients should resist the urge to preserve
time of definitive closure or amputa- with severely mangled lower li mbs. some of the muscle to allow for better
tion. Type III open fractures defini- Therefore, current recommendations function. Retained necrotic muscle
tively closed with delayed primary center on early assessment of the ex- increases the risk of infection and
closure and/or split-thickness skin tent of injury, along with frank dis- provides a nidus for heterotopic ossi-
grafting were classified as type IIIA cussions with the patient to explain fication.

When addressing the bone, the thetic biologic dressing, dressing treat the entire patient and not the
soft-tissue debridement should be sponges, or a vacuum-assisted closure limb in isolation. What is technically
used as a guide for the bony debride- device (V.A.C. Sponge, Kinetic Con- feasible may not be in the best interest
men t. All bony tissues that have mar- cepts, Inc, San Antonio, TX). of the patient. Amputation should
ginal soft-tissue attachments or fail to Once stable, the limb will require not be considered a failure but rather
demonstrate adequate bleeding are additional debridements to further another therapeutic modality. To re-
necrotic and should be excised. This assess tissue viability. All necrotic or turn an individual to preinjury func-
reduces the risk of infection or the contaminated tissue must be excised. tion while limiting pain and suffering
development of osteomyelitis. If significant contamination or myo- is the goal of treatment. If this cannot
The difficulty is trying to deter- necrosis exists, formal surgical de- be accomplished by limb salvage, then
mine when a bony fragment has lost bridements may need to be per- amputation must be considered seri-
its blood supply. Free-floating cortical formed every 24 hours. If the wound ously. We hope that ongoing multi-
fragments completely stripped of pe- is not grossly contaminated, debride- center prospective studies will pro-
riosteum or muscle attachments are ments performed every 48 to 72 duce clinically validated guidelines for
devitalized and should be discarded. hours should be sufficient. The initial amputation and salvage.
Diaphyseal bone that is stripped but antibiotic regimen of aminoglycoside
remains in continuity with the re- and penicillin is continued for 48 to
maining shaft or metaphyseal region 72 how-s after the first debridement
References
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may be more difficult to evaluate. In
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addition, metaphyseal fragments and
Pathophysiology and Care. New York,
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2. Wangensteen 0, Wangensteen S: The
ability to revascularize through the ter each subsequent surgical debride-
Rise of Surgery From Empiric Craft to
abundant vascular bed of the cancel- ment. Although the patient receives Scientific Discipline. Minneapolis, MN,
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quately with internal fixation. There- tion. analysis of 2471 cases. Ann Surg 1946;
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Once a clean surgical wound bed sively covered and closed, ideally Am J Surg 1969;118:53 1-534.
has been created, stabilizing bone is within 5 to 7 days after the injury. 5. Hicks JH: Amputation in fractures of
the next step. Early stabilization with Closure can be accomplished either the tibia. J Bone Joint Surg Br 1964;46:
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fixatio n is used. The choice of exter- vascularized free-tissue transfer. If sitions in employment, morbidity, and
nal or internal fixation depends on this treatment regimen is successful, disability among persons ages 51-61
the wound and bony injury. The fixa- the surgeon has transformed a mas- with musculoskeletal and non-
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7. Bondurant FJ, Cotler HB, Buckle R,
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Miller-Crotchett P, Brovmer BO: The
methylmethacrylate beads made by with bone grafting, vascuJarized bone
medical and economic impact of se-
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braided 26-gauge wire or a No. 5
braided suture. In addition to provid-
Conclusions et al: The salvage of grade IllB open
ankle and talus fractures. J Orthop
ing a high concentration of local anti- When massive trauma to the lower Trauma 1990;14:585.
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for a later bone graft. 34 Surgical ex- must make difficult decisions. Al- Earle AS, Simmons AL: Open tibial
tensions of all wounds should be pri- though treatment has changed signif- fractures with severe soft-tissue loss:
marily closed, whereas traumatic icantly over the past 200 years, many Limb salvage compared with below-
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or temporarily covered with a syn- the obligation of the physician to Am 1994;76:1594-1595.

10. Butcher JL, MacKenzie EJ, Cushing B, Mangled Extremity Severity Score. 27. MacKenzie EJ, Bosse MJ, Kellam JF, et
et al: Long-term ou tcomes after lower Clin Orthop 1990;256:80-86. al: Factors influencing the decision to
extremity trauma. J Trauma 1996;4 l: 19. Lange RH: Limb reconstruction versus amputate or reconstruct after high-
4-9. amputation decision making in mas- energy lower extremity·trauma.
11. Pezzin LE, D illingham TR, MacKenzie sive lower extremity trauma. Clin J Trauma 2002;52:641-649.
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BD, Weigel MC: Severe open tibial
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17. Johansen K, Daines M, Howey T,
Helfet D, Hansen ST: Objective criteria with external fixatio n. Clin Orth.op 33. Gustilo RB: Management of Open Frac-
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26. Bosse MJ, MacKenzie EJ, Kellam JF, et
1990;30:568- 572. al: A prospective evaluation of the 34. Christian EP, Bosse MJ, Robb G: Re-
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hansen K: Limb salvage versus ampu-
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Surg Am 1989;71:994-1004.

Wartime Amputee Care
Introduction
Amputees represent a small but sig- mJury para.mount for military sur- of the international community and
nificant group of combat casualties geons to provide the best care for the nation itself.
who requfre longer hospital stays, their patients. There has been a steep
more surgical care, and prosthetic fit- learning curve concerning the care of
ting compared to the average battle amputees with every conflict during
The Civil War
casualty. The wars of the 20th century the 20th century. Indications for Amputation
have found surgeons relearning the The latest surgical techniques from Surgery evolved during the Civil War
principles of amputee care and using civilian practice are often inappropri- as did the overall care for the
the technique of open circular ampu- ately applied to patients who must be wounded soldier. Early in the war
tation and skin traction as the initial transported from the combat zone. American surgeons relied on accounts
surgical procedure in theater. The The goals of initial care must take from the Napoleonic Wars and from
techniques and special postoperative into account the deleterious effects of the Crimean War for guidance on in-
care for these patients are not rou- evacuation; thus, initial surgery dications, techniques, and postopera-
tinely taught in surgical training pro- should prepare the patient for the tive care of amputees.
grams in the United States. Amputees trauma of transportation. In the case Macleod 1 reported on amputees
are often the most severely injured of amputees, wound closure is often during the Crimean War (1853-1856).
patients seen on the battlefield and attempted to provide a residual limb Amputations were performed in ei-
require priority care at forward surgi- so that a prosthesis may be fitted as ther the primary or secondary peri-
cal echelons. soon as possible. As documented in ods, depending on how long after i.n -
Conflict can occur without warn- World War I, World War II, and Viet- jury an amputation occurred.
ing and find US military surgeons nam, early wound closure in battle- Primary amputations occurred soon
treating battle casualties with little or field hospitals has been shown to in- after injury, either before or after
no preparation. It is the goal of any crease the complication rate. shock lbut before sepsis developed.
military surgeon to be prepared to Over the past several years, the Secondary amputations occurred af-
treat battle casualties and to minimize Army Medical Department has aster sepsis or inflammation had oc-
morbidity and mortality, even with sumed responsibility for other mis- curred. Indications for primary sur-
large numbers of patients. Prepared- sions. Care of refugees and patients gery included open fractures, partial
ness therefore not only involves the who are not US or Allied soldiers, and or complete traumatic amputation,
ability to treat battle casualties but therefore are not evacuated, has and fracture combined with an open
also to instruct others on their care. changed the traditional role of mili- joint injury. Secondary surgery was
Amputees have historically been a tary surgeons. These days both initial performed when a patient had a clin-
significant clinical problem for mili- and definitive care occurs in theater. ically infected wound. Primary ampu-
tary surgeons because of (1) the se- Patient facto rs are also variable. The tation was preferred because patients
verity of injury, (2) high morbidity, patients may be any age or sex and with infection were at increased risk
and (3) long hospital stays. Very few may have a variety of nutritional and of death. Macleod reported a mortal-
surgeons have extensive experience health problems. Prosthetic fitting of ity rate of 37% with primary amputa-
caring for amputees in civilian prac- the amputated limb is also highly tions and 60% with secondary ampu-
tice, making the study of this type of variable and depends on the resources tations; overall the mortality rate of

both groups was 39.8%. His series fo- that "conservatism" with open frac- !ished hospitals for their regiments
cused principally on casualties that tures was not generally indicated in (approximately 440 men) behind the
occurred late in the war. military surgery except in injuries battle area and operated on soldiers
Two techniques used during the with minimal soft-tissue disruption. from their units. Letterman trans-
Civil War were (1) a circular tech- Indications for secondary surgery formed various regimental hospitals
nique in which the incisions were were secondary hemorrhage, rapid into aid stations, with one assistant
made circumferentially around the drainage, "mortification," decreasing surgeon who provided care and trans-
extremity; and (2) a flap technique in patient strength, "necrosis or malig- port to a field hospital at the division
which flaps were made to facilitate nant disease of bone defying treat- level. Medical assets from three to
closure. Macleod preferred the circu- ment;' diseases of joints, and tetanic four regiments were used for these di-
lar technique for battle casualties be- symptoms. If a patient's condition vision field hospitals. Three surgeons
cause it preserved residual limb was such that he could not be trans- were designated as operators, and
length for prosthetic fitting. ported without deteriorating, ampu- others handled records and supply.
Surgery and anesthesia techniques tation was advised. The conversion to Letterman's system
evolved between 1861 and 1865, and was gradual but in place when the
changes were made in the field hospi- Early Techniques
Army of the Potomac fought the Bat-
tal system, resulting in better care for Amputations during the Civil War tle of Fredericksburg. 10- 13
the wounded soldier in a number of were performed using either the flap By 1863, as surgical techniques
ways. Indications for amputation also or circular techniques. Flaps were evolved and surgeons became more
evolved. In the Crimea, amputations constructed in a variety of sizes and
experienced, indications for amputa-
were performed for gunshot fractures shapes to include anterior/posterior,
tion were becoming more refined.
and for mangled limbs. Secondary medial/lateral, or single anterior or
Gunshot fractures of the femur were
amputations were perfor med to treat posterior flap. Advocates claimed that
not always necessarily an indication
sepsis. flap amputations provided better
for amputation. Moses 14 in 1863 re-
Gross,2 writing in 1861, listed the soft-tissue coverage and were faster to
ported a 12.9% incidence of amputa-
following indications for amputation: perform. The circular amputation
tion associated with long bone frac-
crush injury, nerve or blood vessel in- technique consisted of a circular inci-
tures for the battles around
j.ury, gunshot fracture with extensive sion with subsequently more proxi-
comminution, a major open joint in- mal cuts in muscle and bone to pro-
Chattanooga. Hodgen 15 and Lidell 16
jury accompanied by a fracture, or ex- duce a concave open residual limb. reported good results in treating gun-
tensive soft-tissue injw·y. Hamilton3 shot fract ures of the lower extremity
The circular amputation was th ought
echoed similar indications in the to preserve residual limb length and in Hodgen splints. Hodgen bin1self,
same year and specifically noted that was considered safer.3 -8 who treated survivors of the long
gunshot fractures of the femur were Fisher,9 writing after the battle of evacuation from the battlefield to a
generally an indication for amputa- Antietam in September 1862, stated large hospital in St. Louis, felt that
tion. Surgery was recommended as that early in the war Confederate sur- amputations should be performed
soon as possible in the primary pe- geons tried to preserve limbs, which only in patients who had injuries to
riod of the first day before sepsis had often necessitated secondary amputa- joints, blood vessels, or nerves. Swin-
developed. 1- 3 tions. Minie balls accounted for 75% burne5 advocated amputation surgery
Confederate surgeons published of the injuries leading to amputation, for a partial or complete traumatic
similar recommendations in 1861. followed by grape shot (12.5%) and amputation, extensive soft-tissue in-
Warren 4 advised that amputations be shell fragments (10.7%). jury associated with nerve or blood
performed as soon as possible and Letterman 10 who was the medical vessel injury and denuded bone, loss
listed partial or complete amputa- director of the Army of the Potomac, of a major blood vessel, or compound
tions and comminuted open fractures reported that the incidence of ampu- fractures of the knee or ankle joint.
as indications for primary surgery. Af- tation varied widely. In the Battle of Most gunshot fractures were treated
ter a period of shock but before infec- Fredericksburg, Virginia, in Decem- nonsurgically during the war, and a
tion developed, he advised amputa- ber 1862, 13.4% of the wounded in variety of splints were developed to
tion for a partial or complete the 9th Corps required amputations, treat fractures. 13- 16
traumatic amputation, compound or whereas the incidence was 3.6% in the Later in the war, Hamilton 17 in
multiple fractmes, complicated frac- 5th Corps. Amputation was the most 1865 recommended that the ideal
tures (ie, major nerve or blood vessel common operation performed on time to amputate was when shock had
injury), fracture associated with an wounded soldiers. 10•11 subsided but no infection was
open joint injury, severe soft-tissue Letterman was also responsible for present. The primary period was ideal
injury, and fracture associated with a reorganizing the field hospital system. but within narrow limits. He advo-
severe soft-tissue injury. He stated Initially, regimental surgeons estab- cated the circular technique for tl1e

Chapter 7: Wartime Amputee Care 79
mended that the artificial limb should drainage of the wound. He also con-
TABLE 1 Amputation Levels Reported be of the same size and shape as the sidered the flapless amputation to be
Du ring the Civil War
limb replaced; of light, strong, and a two-staged procedur~ in which the
Otis and durable materials; and "well fitting to second procedure was performed at a
Huntington 18 Fisher 9
(%) (%)
the residual limb." He felt that the An- differen t tin1e under less urgent cir-
Shoulder 4.2 7.0
glesea and Bly legs were most appro- cumstances. He described a cfrcum-
Arm 26.8 35.0
priate because botl1 had an ankle ferential skin incision in which tlle
Elbow 0.9 NIA
joint. Palmer legs, which had a solid skin and subcutaneous fat were al-
Below elbow
ankle, were also popular. It is not lowed to retract as one layer, and the
8.5 7.0
Wrist
known how many amputees used muscle and bone were divided more
NIA NIA
prostheses because many lower limb proximally. Nerves were tied and cut
Hip 0.32 NIA
amputees walked with ambulatory short to prevent development of neu-
Thigh 30.0 22.8
aids, such as crutches, rather than romas. Blood vessels were also tied
Knee 0.94 NIA
disarticulation wearing a prosthesis. Otis and Hun- and transected. Indications for sur-
Leg 26.8 28.0 tington 18 reported that 40 to 60 pa- gery were gas gangrene, compotmd
Foot 0.8 NIA tients with knee disarticulations were comminuted fractures, and multiple
fi tted for a prosthesis. wounds (multiple fragment wounds
Amputee care changed during the from explosive devices). The advan-
Civil War as surgeons became more tages of this technique included easy
forearm and leg but flap amputations experienced. Use of splin ts for the drainage to prevent widespread sep-
treatment of open fractures became sis, preservation of residual limb
for the thigh and arm .
more common during the later stages length, and decreased risk of second-
Epidemiology of the war. ary hemorrhage. He also recom-
mended skin traction to prevent bone
Otis and H untington 18 recorded the
protrusion.
largest collection of information on World War I This surgery was often erroneously
battlefield casualties from the Civil
called a "guillotine" amputation, in
War. The Army Medical Museum re- The United States became officially
which the soft tissues and bone are all
corded 253,142 casualties in the Civil involved late in World War I (1917),
transected at one level. Controversy
War; about 20,559 patients (8.1%) whereas the other Allied aTnlies were
over tl1e terms and the type of ampu-
had significant amputations (those involved from the beginning. Many
tations to be performed in field hos-
proximal to the wrist or ankle) . In American surgeons learned the care
pitals continued for tl1e rest of the
this series, transfemoral amputation of amputees from Allied surgeons
war. Th e construction of flaps that
was the most common (Table I ). The who had been involved in the conflict
were to be left open until they could
open circular (or flap less) technique since it began in 1914. Others gained be closed was advocated, and the guil-
was most commonly used. For trans- experience by working with volU11tary lotine procedure was condemned be-
tibial amputees, flaps were used in American hospitals (American Am- cause it required a longer healing
1,720 patients (58.8%) and the open bulance) or with the French and En- time and a second, possibly more ex-
circular technique in 1,206 patients glish hospitals prior to American tensive, operation. 25· 27
(4 1.2%). The total overall mortality involvement. 21 • 24 Blake28 in 1914 helped organize
of amputees was 35.7%. what later became known as the
Early Techniques
American Ambulance, a hospital unit
Postamputation Care Early in World War I, British surgeons composed of groups from medical
Treatment after the amputation var- performed amputations by construct- schools in the United States. The
ied considerably throughout the ing flaps and using delayed primaq units were to rotate every 3 months.
course of the war. Jewett, 19 an army or primary closure. This technique re- Lakeside University (Cleveland,
surgeon at Gettysburg, wrote of sur- sulted in poor-quality residual limbs Ohio), Harvard University, and the
geons using dressings, "coal oil," cas- and infection, which often necessi- University of Pennsylvania eventually
tor oil, water, and other liquids to tated revision surgery to a more prox- sent units. Blake also helped organize
coat the residual limb. Residual limbs imal level. 25 · 27 the American Red Cross Military
that were initially closed would sup- In 1915 Fitzmaurice-Kelly27 re- Hospital No. 2 in Paris in 1917; he re-
purate and break down, as opposed to ported a flapless open amputation in mained commander in 1918 when the
wounds left open. which the level of amputation was at United States became profoundly in-
There was no standardized pros- the lowest viable level of tissue. He volved in tlle war. Over a 4-month pe-
thetic fitting or rehabilitation for considered it an emergent procedure riod, 55 amputations were performed
Civil War amputees. Minor20 recom- that was performed to allow free in this hospital, 70% of which were at

to a base hospital where more defini-

TABLE 2 Amputation Levels Reported During World War I tive care could be provided.
Callendar et al30 Speed 29 Blake 23 Base hospitals were established to
Above elbow 31 (20.5%) 27 (22.3%) 3 (5.8%) provide more definitive care to sol-
16 (10.5%) N/A 2 (3.9%) diers and prepare them for the long
Forearm
60 (39.7%) 71 (58.6%) 38 (74.5%)
transport by ship back to the United
Above knee
38 (25%) 23 (19%) N/A
States. A hospital center was estab-
Below knee
N/A
lished in Savenay, France, wiili Base
Foot 6 (3.9%) N/A
Hospital No. 8 as its core unit. An am-
putation service was established at
that hospital to care for amputees re-
the transfemoral level; overall, 42% their special needs. If an open circular turning to the United States. The
were for gas gangrene, 29% for sepsis, amputation was performed, the pa- goals of this service were to provide
and the remainder for trauma. The tient could be moved safely 1 week af- skin traction, wound care, and physi-
incidence of admissions for these pa- ter surgery. 31 cal therapy. A program of early ambu-
tients was 1.32%. Blake did not rec- In May 1916, the American Ortho- lation on a temporary prosthesis,
ommend the guillotine or open circu- paedic Association meeting voted to designed based on the experience of
lar technique because it required a appoint a preparedness committee to Belgian physicians, was also instituted
second operation for completion and consider the needs of the United at Savenay, and about 20% of the
res.idual limb fitting23•24•28 (Table 2). States in the event of American par- returning amputees were initially fit-
Crile,24 who was commander of ticipation in the war. Major Sir Rob- ted there. 31 ·33
the Lakeside Unit, ctid not recom- ert Jones of Britain requested in tl1e Wound closure was performed in
mend flaps in patients with a contam- spring of 1917 that American ortho- certain cases. During quiet times on
paedic surgeons augment orthopaectic the front, if a soldier had a localized
inated wound or infection. Rather, he
specialty centers to treat returning injury, flaps could be performed fol-
recommended a "flush" amputation
wounded British solctiers. At that lowed by primary or delayed primary
that could be revised when the sepsis
time, about 65% of the serious battle closure. This procedure was possible
was quiescent.
casualties were extremity wounds and only if there were no significant
Speed,29 who was with Base Hospi-
England lacked trained orthopaedic wounds proximal to the amputation
tal (Chicago Unit) in France in 1918,
surgeons. Temporary assignment of site, if the patient was received rela-
reported on 121 amputations. Indica-
American orthopaedic surgeons pro- tively quickly after injury, and if he
tions for surgery were severe frac-
vided them with experience in treat- could be observed for 10 to 15 days
tures, gas gangrene, sepsis, secondary
ing battle casualties prior to their as- afterward. 31
hemorrhage, and trench foot. The
signment in France with the AEF. 32
most common level was the transfem- Number of Amputations
oral (58.6%) . He recommended an AEF Hospitals Of the 550 amputees examined at
open circular amputation with longi- Savenay, 58% were treated by the
The AEF ran three main types of hos-
tudinal skin slits up the side of the re- open circular technique, 30% by the
pitals: ( 1) the field hospital, (2) the
sidual limb. evacuation hospital, and (3) the base flap technique with delayed primary
Evacuation Hospital No. 8 re- hospital. 3 1 Field hospitals, which were closure, and 11 % by primary or de-
ported 151 amputations'in 4,714 bat- located 3 to 8 miles from the front layed primary closure alone. Of the
tle casualties (3.2%) who were admit- lines, provided immediate surgical residual limbs that were closed, 25%
ted from September 13 to November care for soldiers who could not be needed to be reopened because of in-
13, 1918. Of these, 62% were for gan- transported. These patients would not fection.
grene, 33.7% for trauma, and 10.5% survive the long evacuation to larger Kirk34 reviewed amputee records
for sepsis. Again, transfemoral ampu- hospitals farther from the front lines. in the Surgeon General's Office for
tations were the most predominant The goal of surgery at these hospitals patients who were operated on in
(39%) .30 was to stabilize a patient for further France (Table 3). From these records,
evacuation. he learned that soft-tissue injury with
Influence of the American Evacuation hospitals provided the infection as an indication for amputa-
Expedition.a ry Force initial surgical care to most patients tion carried a higher mortality rate
In August 1918, the Chief Surgeon of in France. They were larger (about than compound fractures. Because
the American Expeditionary Force 1,000 beds), located 9 to 15 miles the cumulative numbers of amputees
(AEF) recommended that amputees from the front lines, and provided in this series exceeded the number of
should be assigned as soon as possible initial surgery to prevent infection amputees returning to the United
to the orthopaectic service in light of and stabilize patients for evacuation States, there is some overlap of

TABLE 3 Amputation Levels and Reported Mortality in the Surgeon General's TABLE 4 Number of Amputees
Office Records Returning to the United States in
1918*
Cause of Amputation Number % of Amputations % Mortality
Compound Fractures Amputation % of
Level Number Amputations
Tibia/Fibula 1,564 66 17
Above 554 19. 1
Femur 770 32.8 29 elbow
Knee 8 0.3 37.S Elbow 41 1.3
Pelvis s 0.21 60 Below 215 7.4
Soft-Tissue Injuries elbow
Leg 664 48.8 23 Wrist 26 0.9
Thigh SSS 40.7 24 Hip 0.03
Knee 130 9.5 26 Above knee 1, 145 39.6
Hip 13 9.5 23 Knee 97 3.3
Below knee 330 11 .4
Ankle 131 4.5
Foot 20 0.7
records. In both categories, the num- He later wrote about his experiences Partial foot 280 9.6
ber of transtibial amputations ex- at these two hospitals, where he Multiple so 1.7
ceeded the nwnber of transfemoral treated about 1,700 patients. 35 sites
amputations. Kirk does not speculate Kirk advocated the guillotine pro-
whether revisions at a higher level cedure for war casualties because of * Does not include hand or partial hand
were required for these individuals. 34 its simplicity and because it preserved amputees.
The greatest number of casualties the maximum residual limb length,
in the AEF occurred in 1918, particu- allowed wide drainage to treat infec- and reamputation. Plastic closure was
larly in the fall of that year. The Sur- tion, and enabled earlier transport performed when there was enough
geon General's Office recorded 2,890 than did other techniques. The guillo- skin to cover the area, with removal of
amputees returning to the United tine technique was really the open cir- no more than 1/8 in of bone. Incisions
States (Table 4) . This number does cular technique, which produced a were made through healthy skin only
not include hand or partial hand am- concave residual limb to be main- after all scar tissue had been removed.
putations. Most of these patients had tained in skin traction. Kirk noted When there was protruding bone cov-
lower limb amputations, most com- that at least 95% of the patients who ered by granulations, a plastic resec-
monly at the transfemoral level were received from overseas with guil- tion was indicated whereby an incision
(39.6%).3 1 lotine residual lin1bs needed addi- was made through healthy tissue and
tional care before prosthetic fitting. d issected back to the saw line through
Care Rendered at US Most residual limbs were edematous the bone. The bone end and scar mass
Amputee Centers and had unhealed areas. Other prob- were then removed as a single piece. A
lems included bony protrusion and cuff of periosteum was removed from
Amputee centers were established in
infection. Organisms most often the end and the skin closed. Reampu-
the United States to consolidate the identified from the residual limbs tation of a residual limb was per-
specialized care for this group of pa- were Streptococcus hemolyticus, staphy- formed either for a residual limb that
tients. Walter Reed Army General lococci, Bacillus proteus, and Klebs- was too long to be satisfactory or too
Hospital had the largest census of Loffler bacillus. short to be fitted.
these centers; other centers were es- Preoperative care of Kirk's patients Kirk indicated that ideal residual
tablished at Letterman General Hos- included skin traction, bed rest, and limb lengths were through the middle
pital (San Francisco), Ft. Des Moines, elevation. Radiographs were obtained third of the leg for transtibial ampu-
Iowa, and Ft. McPherson, Georgia. on admission to evaluate the bone tees and through the lower and mid-
General Hospital No. 3 in Colonia, and to look for foreign bodies. Infec- dle third for transfemoral amputees.
New Jersey, was established as an am- tion was treated by dressing changes He did not favor a knee disarticula-
putee center because of its proximity and sodium hypochlorite solution. tion because the condyles are a poor
to harbors where soldiers landed from Surgery was not performed until weight-bearing surface. Rather, he
overseas. By April 1918 the amputee the residual limb had been quiescent preferred to cut the bone just above
service housed 750 patients. Kirk was and radiographs showed no signs the joint line and use an osteoplastic
assigned to the amputee service at of infections, usually after about 6 or tendoplastic closure technique. Up-
Colonia in 1919 and later went to months. Kirk35 described three proce- per limb amputations were more for-
Walter Reed Army General Hospital. dures: plastic closure, plastic resection, giving; if the patient healed with skin

traction and a terminal scar, a second on a temporary prosthesis was insti- uation to a hospital in a more stable
procedure often was not required. A tuted, and then forgotten for many environment. 45• 50
very short transradial amputation was years.33.41 There were also problems with
difficult to fit, and he did not recom - amputee patients. Those who did not
mend bone shortening with amputa- have skin traction after open circular
tions through the proximal third of
World War II amputations experienced bony pro-
the forearm or distal third of the arm. lnterwar Years trusion and needed reamputation,
Once the wound on the residual Advances in the care of amputees be- with the resultant loss of limb length.
limb was closed, there was a period, tween the first and second world wars Amputations in which the skin had
usually of several months, before were principally confined to the im- been closed were seldom successful
edema would subside. During this proved management of shock and the because of infection. A loose closure
time a temporary prosthesis was used. prevention and treatment of infec- was recommended to prevent skin re-
This prosthesis could be mass- tion. Several authors improved our traction and the hazards of a routine
produced and required a minimum of understanding of the pathophysiology closure, with an emphasis on the
fitting. An insert, usually of plaster of of shock and its treatment. 39•41 The speed of the initial surgical proce-
Paris, was made, and the patient use of sulfonamide compounds in ci- dure. Skin traction with the open cir-
could then begin gait training (lower vilian surgery was thought to prevent cular technique was not recom-
limb amputations) or using the upper infection in open fractures, which was mended. After t he attack on Pearl
limbs. At this point, a team of sur- the principal cause of amputation Harbor, patients with delayed pri-
geons, limb fitters (prosthetists), and during World War I. Penicillin, like- mary or primary closure became in-
physical therapists (called reconstruc- wise, was thought to prevent and treat fected and required amputation to a
tion aides at this time) worked to- infections in open fractures. 42 higher level (LT Peterson, unpub-
gether to achieve the best results in The number of amputees for the lished data, 1946).
the minimum amount of time. 36• 38 US Army during the 1920s and 1930s The lack of success with early clo-
Wilson,33 who was in charge of the was not significantly high. Kirk re- sure of wounds led Kirk51 in 1942 to
amputee service at Savenay where a reemphasize the open circular ampu-
mained in the military with posts in
limited program of early walking had tation once again in a technique arti-
the Philippines and at Walter Reed,
begun for lower limb amputees, be- cle he published for those serving or
Ft. Sam Houston, and Letterman
lieved that if the wound was clean, a about to serve. The technique ;it this
General Hospitals. His report on sites
patient could begin ambulating after time was characterized by amputating
of election for lower limb amputa-
2 to 3 weeks. At this time, the patient at the lowest level of viable soft tissue,
tions was published in 1933. 43 The
was put into a temporary prosthesis allowing the skin to retract, and suc-
complacency of the 1930s slowly
consisting of a socket and frame. The cessively cutting layers of muscle and
changed to realization tl1at the United
frame could be prefabricated and bone more proximally to produce a
States might become involved in
needed a minimum of fitting, and the concave residual limb. The residual
World War IL Kirk, sensing the lack of
socket was generally made from plas- limb end allows wide drainage to pre-
preparedness of the US military, re-
ter of Paris and molded to relieve vent infection. He recommended the
vised his amputation text in 1940 to injection of alcohol into the nerves
wound pressure. He believed that
educate the surgeons expected to care before transecting and double ligation
early ambulation promoted wound
for casualties in this new war. He also of large vessels with No. 2-0 silk, cot-
healing, caused residual .limb shrink-
age, improved morale, and decreased wrote about the general treatment of ton, or catgut suture. Postoperatively,
the time to permanent prostheses. combat casualties in 1940 and the patient was to be maintained in
1941 42"44 (AK WiUard, personal com- continuous skin traction to prevent
Care of the AEF amputee was
modern in certain aspects. Several in- munication). retraction of the soft tissues. A repair
novations considered recent were de- or plastic closure of the residual limb
Early World War II
veloped by US Army surgeons during was then performed in patients with
World War I. The team approach, in Experience an adherent scar. In a later article,
which a special service of limb fitters, British experience in the Western Kirk and McKeever52 emphasized that
reconstruction aides (physical thera- Desert of North Africa revealed prob- the open circular technique was a
pists), and surgeons cared for the pa- lems concerning both field surgery two-staged operation requiring a sec-
tients, was developed at the amputee and amputee patients. Armored war- ond surgery for closure of the wound.
centers. The open circular technique fare had become more fluid and mo- The use of this procedure was for-
with postoperative skin traction, a bile than it had been on the western malized in April 1943 by Circular Let-
method applied to battle casualties front of World War I, and the medical ter No. 91, in which the Office of the
today, originated and was developed field service needed to provide initial Surgeon General outlined the use of
during the war. Finally, early walking surgery near the front, as well as evac- the open circular amputation in the-

sualties came from this theater. Battle-

TABLE 5 Indicat ions for Amputation field casualties in this theater opened
Cause of Amputation WWI (%) ETO (%) MTO (%) RVN {%) on June 6, 1944, with the Normandy
Trauma 25.5 64.3 75.0 89.5 invasion and ended witl1 the surren-
Infection 74.5 14.3 9.5 8.4 der of Germany in May 1945. During
Vascular 21.3 14.5 1.9 these 11 months, there was a consid-
erable casualty load and evolution of
WWI = World War I policy. Some experience was learned
ETO = European Theater of Operations- World War II (Third Army only) from the MTO, but the commands
MTO = Mediterranean Theater of Operations-World War II were separate and advances in treat-
RVN = Retrospective chart review of patients at Valley Forge Army General Hospital ment did not necessarily proceed at
{personal records, P. Dougherty) the same rate. Before actual combat
began in June 1944, guidelines were
established outlining the indications
ater, allowing the open flap technique and technique of amputations and
on the move. Evacuation hospitals, in
only in patients who would not be the care of amputee casualties. Tech-
contrast, were farther from the front
evacuated and whose wounds would niques recommended were the open
lines and less mobile; these provided
be closed at a later date at the same circular technique and a true guillo-
initial surgical care for most battle ca-
tine in which the skin, subcutaneous
hospital. Lower limb amputees in the sualties.
continental United States would be fat, fas,cia, muscle, and bone were all
Amputee caTe gradually evolved in
discharged only after they were able cut at the same level. Sulfonamide
North Africa and in the Mediterra-
powder was to be sprinkled on tl1e
to walk on level ground using a tem- nean Theater of Operation (MTO).
wound and then covered with petro-
porary prosthesis without ambulatory Indications for surgery were severe
leum jelly gauze, a technique already
aids. trauma to the limb, usually a partial abandoned in the MT0. 56
or complete traumatic am putation, In July, these policies were
Innovations in Initial vascular injury, or uncontrolled or se-
Management changed. Consultations were now
vere sepsis of the limb. The preferred mandatory before an amputation was
World War II was characterized by a method of amputation was the open performed, and the indications were
more mobile form of warfare than circulaJ" technique witl1 sulfonamide documented in the patient's medical
World War I, and the medical field powder sprinkled on the wound and record. Only the open circular tech-
service of the US Army, like its British petroleum jelly gauze placed over the nique was recommended. Su lfona-
counterpart, evolved to accommodate wound. Skin traction was maintained mide powder was not to be used, and
this new form of warfare. Ideally, ini- for transportation by an Anny half- the patient's wow1d was to be dressed
tial surgical management of a battle ring splint.54 in fine mesh gauze to allow for drain-
casualty occurred at an evacuation or By August 1944, this policy had age, a procedure similaJ" to what was
field hospital, depending on the casu- been modified to discontinue the sul- already used in the MTO. Patients
alty load and the patient's triage fonamides and replace the splint with were to be placed in a banjo cast for
category. 53- 55 a banjo cast with skin traction. The transportation. When amputations
The field hospital, which was open circular technique was empha- were performed for clostridial infec-
meant to handle nontransportable sized as the recommended procedure tion, patients were considered non-
patients, collocated with a clearing in theater, with no cuff of periosteum transportable for 24 to 48 homs and
company in the rear of a division area removed from the end of the residual not placed in skin traction during
and was divided into three platoons. limb. Patients were to be kept in skin that time.
One platoon received casualties from traction for about 6 weeks so that an By November, no split-thickness
the designated clearing company. adherent scar could form and then skin grafts or secondary closmes were
When this platoon was full, or if the transported to amputee centers in the to be performed in theater. Patients
division moved, the platoon stopped continental United States. Secondary could be moved to the continental
taking casualties. When patients could closures of the upper limb or lower United States after 2 to 3 weeks of
be transported, the unit would move third of the leg were performed skin traction at a general hospital.
to a new location, set up, and receive through penicillin coverage, if the These later policies remained in effect
casualties. In the meantime, another wound was clean. 54 ' 55 truough the end of the war. 56
platoon was receiving new casualties. The European Theater of Opera- Indications for surgery in the ETO
This system allowed nontransportable tions (ETO) had the largest casualty and MTO were primarily the effects of
patients to be held until stable, yet load fo r the United States, as about trauma (Table 5), which was in con-
provided continuous care to an army 375,000 of the 600,000 US Army ca- trast to World War I when infection

ducted according to the policies that In June 1943, Circular Letter No.
TABLE 6 Etiology of Inj ury Leading to had been established. Amputations 115 outlined the type of temporary
Amputation in the MTO Time Period prostheses to be used, as well as the
had to be performed at as low a level
Cause of 1943 1944-1945 as possible. Wound closure was not to procurement and supply of tl1ese
Amputation (%) (% ) items at the amputee centers. Circular
be performed in theater. Heavier skin
Fragment 63.7 56.9 traction was needed for older ampu- Letter No. 124, July 15, 1943, outlined
Land mine 19.8 37.5 tations, and leaving excess muscle in tl1e goals of physical therapy before
Gunshot 10 .1 3.8 leg residual limbs was to be avoid- fitting with a prosthesis; these con-
Other 6.2 0.85 ed.so,62 sisted of bandaging to reduce swell-
Once healed, the residual limb was ing, massage, and stretching exercises
to be fitted for a temporary prosthesis to prevent joint contractures.
was the most common cause of ampu- so that the patient could learn ambu- Peterson,62 who was the Ortho-
tation. Hampton 55 documented tl1at latory skills. When the edema had paedic Consultant to the Surgeon
land mines were increasing in preva- subsided and the residual limb had General, documented iliat 14,912 am-
lence as wounding agents in the MTO matured, the patient could be fitted putees were received at the US ampu-
(Table 6). Lower limb amputations with a permanent prosthesis.60· 63 tee centers. More than 90% of these
predominated, with transtibial ampu- Upper limb amputations occurred were received after May 1944, over-
tations the most common, also in con- less frequently than lower limb ampu- burdening centers that, on paper,
trast to World War I when transfemo- tations and constituted a different were planned as 500-bed facil ities
ral amputations predominated. 55"56 clinical problem with regard to func- (2,500 total beds). Two otl1er general
Odom,57 who was the Third Army tion. The goals of care for upper limb hospitals became amputee centers,
surgeon in the ETO, noted that land amputees at the amputee centers were England (Atlantic City, New Jersey)
mines increased the incidence of am- residual Limb healing, fitting of a pros- and McGuire (Richmond, Virginia).
putations in the casualty load. He also thesis, and training in activities of The bed capacity of these hospitals
reported that 9.0% of these patients daily living. Cosmesis also played a also expanded to accommodate the
died of their wounds after reaching larger role in the care of a patient with casualty load.
medical c;are alive. an upper limb amputation. 50062. 65 The high visibility of amputees, as
Mounting casualties and the recog- well as the real and perceived prob-
Management in the United nition that they needed specialized lems of their care, prompted public
States care led Rankin, the Surgical Consult- criticism of the US Army amputee
Once an amputee was ready to be ant to the US Army Surgeon General, program. As a result, civilian consult-
moved to the United States, he was to write Kirk, who in March 1943 had ants inspected amputee centers in
placed in skin traction with a banjo or become the commander of Percy May 1944. The consultants were well-
traction cast to allow for transporta- Jones Army General Hospital in Battle respected academic orthopaedic sur-
tion.ss.s9 Creek, Michigan. Rankin wanted to geons who reported on the quality of
Once in the United States, the place Kirk in charge of an amputation surgery, of the artificial limbs, and the
goals of care at these centers varied program and thought he would be the general care of the amputees. The re-
with the level of amputation.60 -64 Orthopaedic Consultant to the Sur- port was highly commending of the
Lower limb amputees "".ere to com- geon General. program but did not quell com-
plete their residual limb healing. The On June l, 1943, Kirk became the plaints. A second inspection, which
open circular technique had been Surgeon General. Five hospitals, occurred in October 1945, was
used in most amputations, and the Bushnell (Brigham City, Utah), Law- equally commending to the amputee
few secondary closures performed in son (Atlanta, Georgia), McCloskey centers.66"68
the MTO produced poor-quality re- (Temple, Texas), Walter Reed Army
Progress in Prosthetic
sidual limbs. Most patients required a General Hospital (Washington, DC)
second procedure, either plastic clo- and Percy Jones, had been designated Management
sure of the wound or revision. The as amputee centers. Problems already Prior to World War II, no national re-
second procedure could be performed identified were the scarcity of sur- search program, either military or ci-
on a residual limb witl1 healthy gran- geons with experience in the care of vilian, existed to investigate the qual-
ulating tissue and no obvious signs of amputees and the lack of suitable ity of artificial limbs. Initially, the
infection. Closure was performed mass-produced prostheses. Planning military believed that iliis responsibil-
when radiographs showed no seques- for amputees included provisions for ity lay with the Veterans Administra-
trum and were otherwise satisfactory. acquiring suitable temporary prosthe- tion, which had the long-term re-
Follow-up at the amputation centers ses, training personnel, and providing sponsibility for the amputee. The
in the Zone of the Interior was con- physical therapy. 51 ' 54 Veterans Administration procured

nearly all of its prostheses from com- paedic surgeon with an interest in limb, was reported by a commission
mercial manufacturers and therefore cineplastic amputations, helped im- that tomed Europe in 1946. This type
lacked its own experienced prosthe- prove function in upper limb ampu- of socket gained popularity in Ger-
tists and engineers. tees by use of this technique. Because many in the 1930s and ~as well devel-
The National Research Council es- of his experience and a smaller pa- oped in that country. The socket was
tablished a Committee on Artificial tient load (758 patients from 1943 to tested at the University of California
Limbs at the request of the Surgeon 1945), casualties received at Mare Is- at Berkeley in the late 1940s, and by
General in February 1945. The com- land received high-quality intensive l 949 this socket was referred to the
mittee was chaired by Paul E. Klop- care that was not possible at other Veterans Administration hospitals for
steg of Northwestern University in centers. genera] use. 68 •70•79
Evanston, Illinois. The goals of the It is difficult to ascertain how
committee were to assist the Army, many limbs were amputated after the Effects of Cineplastic
Navy, and government in the early war because of chronic problems, Techniques
procurement of the best prostheses to usually infection, due to battle inju- Studies on · cineplastic techniques
meet the demands of World War II. ries. Spittler and Taylor78 docu- whereby a muscle (pectoralis or bi-
Additionally, the committee was to mented 150 amputations performed ceps brachii) was used to power an
sponsor studies on the mechanical in 1947 and 1948 at Walter Reed upper limb prosthesis were also con-
behavior of both normal and artificial Army General Hospital. Most of these ducted at the University of California
limbs, study existing prostheses, and patients required amputation because at Berkeley to identify the idea,I place-
dfrect research toward improving, of long-standing osteomyelitis. ment of tunnels and the amount of
simplifying, and standardizing artifi-
force generated by the muscles. 74 •80
cial limbs as much as possible. This
included investigating potential new Postwar Research The Anny had its own prosthetics re-
search laboratory at the Forest Glen
materials to manufacture limbs, and the Korean War Annex of Walter Reed Army General
studying the art of limb fitting, and
The Committee on Artificial Limbs of Hospital. This laboratory was devel-
training the amputee in its use. By
the National Research Council spon- oping and testing upper limb prosthe-
August 1945, Kirk noted improve-
sored research at various institutions ses, including the Army Prosthetics
ments in upper limb prostheses, the
at the instigation of Kirk in an effort Research Laboratory (APRL) hook.
use of plastics, the testing of many
different joints, and the use of rubber, to standardize artificial limbs as much The hook remains open and cable
fabric, and bonding methods recom- as possible. Initial funding in 1945 pressu re causes it to close, which is
mended by the National Bureau of came from the wartime Office of Sci- the opp osite mechanism for all hooks
Standards.69"72 entific Research and Development, at that time. 80
Basic research was conducted at and later funding was provided prin- Brav and associates 8 1 at Walter
the University of California on gait cipally by the Veterans Administra- Reed Army General Hospital studied
and the use of muscles to power an tion. cineplastic techniques beginning in
upper limb prosthesis; the latter was Initially, no laboratory was specifi- 1948 to determine the true value of
known as a cineplastic operation. cally established to evaluate ampu- the procedure and develop any advan-
Lower limb studies focused on identi- tees. Problems remained in two areas: tages it might possess. They per-
fying the elements of normal gait, the ideal reproduction of limb func - formed 78 biceps and 29 pectoral
principles that are still used today. tion and the production of materials cineplastic operations. At the end of
This research, begun in World War TI, suitable for artificial limbs. Additional 1 year, 73.1 % of patients in the biceps
was ongoing for several years and led studies were clearly needed to identify group and 31 % in the pectoral group
to improvements in prostheses. 73•75 the scientific parameters of gait to ef- were still using their prostheses.
Combat trauma in the Navy and fectively reproduce them with an arti- The authors concluded that biceps
Marine Corps resulted in 1,343 signif- ficial limb. In the late 1940s and early cineplastywas advantageous for trans-
icant amputations, which necessitated 1950s, Saunders and associates,73 In- radial amputees because the shoulder
the establishment of two additional man and Ralston,7 4 and Levens and harness could be eliminated, and the
amputee centers-one at Mare Island, associates 75 studied normal and ab- prosthesis could be used above the pa-
California, and the second in Phila- normal gait by filming and measuring tient's head or behind tl1e back. This
delphia. The clinical experiences of gait in individuals with and without procedlme resulted in increased kines-
these two centers were published in amputations. Many of their findings thetic sense for the patient that was
separate symposia in the US Naval are still relevant today. not provided by conventional pros-
Medical Bulletin in 1945 and A suction socket, one in which theses. Transhumeral amputees could
1946.76 -77 The Mare Island experience there is slight negative pressure to have more control close to the body
was unique in that Kessler, an ortho- maintain contact with the residual while performing multiple tasks with-

out undergoing locking/unlocking patients listed with amputations re- phenicol, and bilateral hip disarticu-
procedures. Pectoral cineplasty of- sulting from battle wounds, 33.4% lations. The most significant survival
fered few advantages, except in the died (460 were listed as killed in ac- rates occurred when alJ measures
case of bilateral shoulder disarticulation and 69 as died of wounds), illus- were used. 98•99
tions in which any extra control was trating the destructive nature of these
welcome. 8 1- 83 injuries.9 1 Studies of severely injured
Patient selection for cineplasty was battle casualties by the Surgical Re- Vietnam War
critical because it involved extensive search Team at the 46th Surgical Hos- The experience of World War II and
surgery and training. A team consist- pital reported that the 140 patients
Korea was not routinely taught to stu-
ing of surgeons, physical therapists, admitted with a major amputation
geons prior to deployment to Viet-
and prosthetists was considered es- during the study period had a hospi-
nam. As a consequence, treatment of
sential for success. Cineplasty is no tal .m ortality rate of 7.85%.92
amputees in fo rward hospitals was
longer used in the United States be- Successful repair of vascular inju-
ries in forward hospitals became pos- not standardized and occasionally
cause of the advent of myoelectric
sible during the Korean War, which compromised patient care, especially
arms, which require less training, and
the fact that surgeons cannot attain reduced the amputation rate from in the earlier stages of the war. As ca-
the experience necessary to become 50% (in patients with ligated vessels) sualties increased, amputee centers in
efficient in this procedure. 81 - 86 to 13% (in patients who underwent the continental United States slowly
vascular repair) .93 -96 began to handle the specialized care
Korean War Howard 97 concluded that the required by these patients.
The Korean War found the US Army "most massive wounds seen in mili- The incidence of amputations at
Medical Department with several or- tary surgery were traumatic amputa- surgical hospitals in Vietnam ranged
thopaedic surgeons who had World tions that occur in land mine war- from 4.5% to 5.6%. Most patients had
War II service still on active duty. 87 fare" and that "clinical experience either partial or complete traumatic
Indications for surgery during this clearly indicated that traumatic am- amputations as a result of their inju-
conflict included complete destruc- putation of the foot at the ankle is not ries, necessitating only completion of
tion of the blood supply and diffuse nearly so severe ru1 injury as a trau- the residual limb. Trauma was the pri-
clostridial myositis. Consultation with matic amputation of the mid thigh." mary indication fo r amputation in
the chief of surgery or senior surgeon, He suggested that bilateral transfemo- more than 90% of patients in Viet-
along with documentation in the ral runputees were in their own spe- nam, followed by vascular complica-
medical record, was encouraged. Am- cial category because they had sus- tions (6%), and infection (3%) . 100•101
putations were considered lifesaving tained "the most massive injury seen Late amputations were performed
procedures and were performed in in battle." On admission, these pain cases of infection, either from an
two stages, the second of which (clo- tients were typically in shock that open fracture or as the result of a
sure) would be performed in the con- could not always be explained by failed vascular repair. Schmitt and
tinental United States. Initial manage- blood loss, suggesting other mecha- Armstrong 102 reported that about 186
ment of battle casualties consisted of nisms for decreased blood pres- (40%) of the 385 patients treated at
the open circular technique at the sure. 101, 102
Clark Air Force Base in the Philip-
lowest level of viable soft tissue. Dis- Studies of the severely injured con-
pines were in that group. The precise
articulations were not considered ap- tinued into the 1950s at Edgewood
number of late amputations per-
propriate because of profuse drain- Arsenal. Using a goat animal model,
formed because of osteomyelitis is
age, difficulty with skin traction, and Lindsey and associates 98 created bilat-
not known. Bagg, cited by Burkhal-
the perceived difficulty in handling eral open femur fractures with mas-
ter, 103 reported that 6.5% of open
the residual limbs. Patients were to be sive destruction of soft tissues to
study what therapy would prolong tibia fractures incurred in Vietnam
placed in transportation casts for
evacuation to Japan and the United survival of the animals and what resulted in amputation when they
States.87- 89 measures could be taken to delay ini- were evaluated in Japan.
Late amputations were performed tial surgery. The effectiveness of in- The Wound Data and Munitions
in Japan often more than 2 or 3 days travenous fluids, blood, antibiotics, Effectiveness Team (WDMET) re-
after the wound was incurred in Ko- and debridement was tested. Debride- corded 98 significant amputations in
rea. In LaZerte's90 report on 104 pa- ment consisted of bilateral hip disar- their series (RF Bellamy, personal
tients with 108 amputations, indica- ticulations. Compared with controls, communication). Of these, 35 pa-
tions for late surgery were ischemic aU therapeutic measures worked: tients died before reaching medical
gangrene (58% of patients), destruc- blood alone, penicillin (preinjury and care and one patient died of wounds
tive trauma (35%), and gas gangrene within 12 hours postinjury), chlortet- after reaching medical care alive, a
(7%). In another study, of the 1,580 racycline hydrochloride, chloram- mortality rate sinular to that caused

by land mine injuries in the Bougain- Rather, LaNoue recommended that eral Hospitals. Only Valley Forge,
ville Campaign. the hindfoot be left intact and that however, established an amputee ser-
simple wound debridement be per- vice that combined the skills of the
Valley Forge Army General formed, leaving the choice of defini - physical therapist, surg.eon, and pros-
Hospital Experience tive amputation to the receiving phy- thetist onto one team. A staff psychia-
Amputations were cau~ed by land sician. The devascularized heel flap trist was added to the team in January
mines and booby traps in 62% of the did poorly when a patient was trans- 1971. T he goals of treatment in these
patients who were examined at Valley ferred to the United States from Viet- hospitals were to provide residual
Forge Army General Hospital (AM nam. limb healing, ambulation training
LaNoue, MD, Ft. Leavenworth, KS, LaNoue concluded that initial am- (for lower limb amputees) or training
unpublished data, 1971 ). Land mines putations in theater should follow in activities of daily living (for upper
in Vietnam were unconventional de- three principles. First, maxinwm limb amputees), an initial prosthesis,
length should be preserved and defin- and a medical board that would allow
vices made from other ordnance or
itive procedures ignored until a stable for medicaJ r.e tirement. 106· 107
imorovised out of local materials.
transfemoral environment could be provided. Sec- .uy J.7V7 Wt: lJWUUC::i U1. dllivtitee.S
Transtibial (i
ond, if a definitive procedure was had become large enough to justify a (27% to 31 o/o;
rtions were the
necessary, the environment must be separate service at Valley Forge Army most commo
singly, patients
stabilized and the evacuation de- General Hospital. Patients evacuated who had lost
:ban one limb
ferred. Finally, skin traction needed to from Vietnam were placed with other comprised 161
battlefield ca-
be maintained on all residual limbs amputees, evaluated, and started on a
sions at Valley sualty amput(
wherever possible. program of residual limb healing and
Hospital and Forge Army
Seligson and Baily104 performed 92 physical therapy. Later, patients were
who were re- 19% of the a
acute combat amputations in 70 casu- fitted with a temporary prosthesis to
tl treatment fa- ceived alive at
walk or perform activities of daily liv-
data. It is un- alties between 1970 and 1971. Of cility in the \I
ing. Because the numbers were signif-
;e was due to these, 24 underwent primary closure known if thi1
icant, these amputees were widely
·e, which pre- and 10 bad delayed primary closure. improved me
studied. The treatment of amputees
ly injured, or if Indications for acute combat amputa- served the mo
generally followed a series of succes-
n the type of tion included (1) time between injury there was a ,
sive stages, consisting of (1) wound
mericans. and surgery of less than 8 hours, weapons used
healing, (2) preprosthetic training,
11ded technique (2) closure that did not sacrifice use- While the r
(3) fitting of provisional prostheses,
~n circular am- ful bone, (3) no significant trauma at this time w :
and (4) fitting of permanent prosthe-
·ative skin trac- proximal to the amputation, and (4) putation with
ses. Patients generally progressed
tars, this tech- the patient would be held at the hos- tion, as in p(
from one stage to the next in sequen-
s used. In his pital for 2 weeks before evacuation. nique was n~
tial order. Each member of the treat-
:es received at The authors did not report any in- series of 410
ment team was responsible for a spe-
meral Hospital crease in morbidity with these pa- Valley Forge ,
cific stage. During wound healing, the
10, LaNoue re- tients; however, the study was limited surgeon provided most of the care. between 1969
the transtibial to a 2-week follow-up. Wilbur and as- Durirtg preprosthetic training, the ported that ,
osure prior to sociates105 reported that 28% of 300 therapists worked primarily with the amputees had
this group in- battle amputees who were admitted to patient. The prosthetist gradually be- evacuation ar
tte due to gross Philadelphia Naval Hospital had un- came involved during the provisional curred a 56%
d that the time dergone wound closure prior to ar- and permanent prosthetic stages. 108 infection. He :
'{ to the date of rival. They also reported that only An innovative early ambulation from the date
ased from 9 to 44% of all amputees had skin traction program was initiated at Valley Forge prosthetic fit ·
,s ure was per- before arrival. Both reports show the Army General Hospital to shorten the 11 months
cuation (AM less than optimal results that occur stages of rehabilitation. Patients am- formed befc
when a few simple principles are not bulated earlier, even on open residual LaNoue, stud(
I USArmyC &
:s). followed. limbs, which allowed patients to be- GS, Ft. Leaven
ed an 88% fail- come upright sooner in an effort to LaNoue als
1putations per-
Long-Term Follow-Up of attain an earlier proprioceptive sense. ure rate in S
:essitating con- Vietnam Amputees Moreover, weight bearing on lower formed in th<
at a transtibial Significant numbers of US Army am- limb amputations reduced swelling. version to am
:urred because putees received treatment at Letter- The hard socket allowed for compres- level. This fa
illy devascular- man, Fitzirnmons, Walter Reed, sion of the residual limb and de- the heel pad v
the hindfoot. Brooke, and Valley Forge Army Gen- creased edema, which was thought to ized by re

followed by vascular injmy (8.4%) seeking help compared with 50% of

TABLE 7 Etiology of Injury Leading to and infection (1.9%). group two.
Amputation-Valley Forge Army All respondents were presently
General Hospital I also conducted a long-term
follow-up of these patients to ascer- wearing prostheses, with the first
% of tain the lifetime effects of such inju- group averaging 15.9 hours per day
Cause of Amputation Amputations
ries.109 Patients were surveyed regard- and the second group, 15.7 hours.
Land mine/Booby trap 64
ing their prosthetic history and family Most respondents reported that they
Small arms 9.4
life, including the following: marriage had changed prostheses, specifically
Rocket-propelled 6.3
and children; number of additional 78.5% of group one and 72% of
grenade
surgeries since their initial amputa- group two. The most commonly re-
Mortar 5.2
tion; psychiatric history, including ported changes were in the foot (22),
Grenade 4.8
membership in Alcoholics Anony- suspension (20), liner (18), and
Artillery 3.9
mous and marriage counseling; other socket (8). The average number of
Rocket 3.7
injuries; and work history. prostheses used since the first perma-
nent prostheses were fitted was 7.89
Transtibial Amputees (range, 3 to 30) in group one and 8.84
allow earlier prosthetic fitting. Finally, Amputation at the transtibial level is (range, 4 to 30) in group two. Patients
the psychological benefits associated the most common in war amputees, reported an average of 1.94 opera-
with being upright sooner and earlier representing 37.8% of the amputations since their initial amputation
independence were well documented. tions in this series. 108 Land mines and (range, 0 to 13), with 1.36 in group
The team approach of the amputee booby traps were the most common one and 2.32 in group two.
service at Valley Forge Army General cause of injury leading to amputation Ertl osteoplasty produces an end-
Hospital was not always possible on (65.3%), followed by mortar frag- bearing residual limb for transtibiaJ
the general orthopaedic service. The ments (17%), small arms (8.5%), in- amputees by creating a bony synosto-
entire team on the amputee service juries inside of vehicles (5.5%), and sis between the tibia and fibula at the
followed patients' progress from ad- rocket-propelled grenades (3.9%). In- distal end of the residual limb. Deffer
mission to discharge, providing more dications for surgery were partial or and associates, 110 Deffer, 111 and
comprehensive care to the patient and complete traumatic amputation in MoU 112 reported that this procedure
ultimately better function. 82% of patients, infection in 13%, resulted in a more stable and durable
I reviewed the records of 484 battle and failed vascular repair in 5%. residual limb. Comparison with other
amputees who were treated at Valley Evacuation time to Valley Forge aver- transtibial amputees was not docu-
Forge Army General Hospital (hereaf- aged 3.5 weeks from the time of in- mented, however, and the definitive
ter Valley Forge) for level of amputa- jury. Average time to pylon fitting was benefits of this level of amputation
5.3 weeks (range, 2 to 16 weeks), and over the conventional transtibial am-
tion, indication for initial surgery,
time to permanent prostheses was 6.8 putation remain unclear. The Ertl
and mechanism of injury. 108,109
months (range, 1 to 14 months). procedure was performed in 42 pa-
Groups of amputees were evaluated
Of the 123 patients eligible for the tients (63%), 19 in group one and 23
from time to evacuation to arrival at
study, 72 (59%) were available for in group two. 108 One patient reported
the hospital, and time to initial (py-
follow-up, and these were divided having had the bone block removed
lon) and permanent prosthetic fitting.
into two groups. One group had iso- because of pain. The SF-36 scores for
Unilateral transtibial amputation was group one were not significantly dif-
lated transtibial amputations, and the
the most common during World War ferent (P < 0.01 ) from the controls.
second had at least one other major
II, and the trend continued. I found a injury (polytrauma), defined in this Group two patients were significantly
higher proportion of multiple ampu- study as a major lower Limb long bone different in all areas (P < 0.01) .
tees (15.9%) than other studies, prob- fracture, burns over more than 20%
ably because Valley Forge was a refer- of the body surface area, and/or sig- Transfemoral Amputees
ral hospital where the more severely nificant head, face, chest, or abdomi- The review of records showed that
wounded patients were concentrated. nal wounds. Most of the patients (44) 59% of these patients were injured by
Mechanism of injury is shown in were in the second group. A compari- land mines and booby traps. Indica-
Table 7. Sixty-four percent of the pa- son of employment, marriage, and tions for surgery were trauma in
tients were inj1:1red by land mines or family factors showed no significant 61.8% of patients, failed vascular re-
booby traps. Small arms, exploding difference between the two groups. pair in 29.2%, and infection in 8.7%.
munitions, and rocket-propelled gre- However, the reported incidence of The average time to Valley Forge was
nades accounted for the other ampu- psychological ca.re differed signifi- 4.4 weeks and to pylon was 4 weeks,
tations. Trauma was the cause of am- cantly (P < 0.001) between the two with permanent prosthetic fitting at
putation in 89.5% of patients, groups, with only 21o/o of group one an average of 7 months. At follow-up,

at an average of 28 years after injury, of 17 patients showed that they were sense of accomplishment in these am-
51 % of those alive and eligible for the fitted with permanent prostheses an putees, all of whom were young and
study agreed to answer the question- average of 6.5 months after injury previously athletic. It ts unclear how
naire. Of those, 93% are or were mar- (range, 3 to 12 months). many of iliem maintained such a high
ried, 91.3% are or have been em- Three patients died since leaving level of function once discharged
ployed, and 85% have children. 113 Valley Forge, and 23 of the remaining from tihe mrntary.
The average number of operations 27 (85.2%) agreed to answer the The autobiography of Lewis Puller
on the residual limb since the initial questionnaire and SF-36 form. Six- documents the trauma of a young in-
amputation was 2.4. Six patients teen of the 23 (69.5%) are employed dividual who becomes a multiple am-
(13%) do not presently wear a pros- outside the home even though they putee. n16 Puller spent approximately
thesis; the others wear theirs an aver- have adequate compensation from the 2 years undergoing treatment and re-
age of 13.5 hours per day and have Veterans Administration to maintain habilitation after stepping on a booby
owned an average of 13.8 prostheses a modest lifestyle. Twenty-one trap improvised out of a cannon
since their initial fitting. Of those (91.3%) are or were married, and 20 shell. He lost'both legs, one at the hip
who wear a prosthesis, half have (87%) had children. Five patients
and one at midthigh, and had partial
changed their prescription since the (21.7%) reported the use of mental
amputations of both hands.
initial fitting. Twenty-four patients health services.
Herndon and associates u 7 re-
(52%) reported seeking psychological Five patients (21.7%) reported that
ported on patients who had femur
care, including Alcoholics Anony- they still wear a prosthesis for an av-
fractures, in addition to their amputa·
mous and marriage counseling. erage of 7.7 hours per day. Ten others
tions, and used a cast brace and early
SF-36 scores were significantly lower (43.4%) report using their prostheses
ambulation. Patients averaged 22
(P < 0.05) in all categories except an average of 12.8 years after leaving
weeks to healing, had less than 1 cm
mental health. Valley Forge. Five patients report us-
of shortening, and an average of 75°
ing prostheses today primarily for
Bilateral Transfemoral "going out." of knee motion. In another study,
Amputees Herndon and associates 118 reported
The SF-36 scores of bilateral trans-
Thirty patients (6.2%) were identified femoral amputees did not signifi- three cases of Mycobacterium fortui-
as bilateral transfemoral amputees, tum infections in the patients who
cantly differ from those of controls
which is a relatively higher frequency except in the area of physical func- were treated surgically because of re-
than expected, probably because the tion. It is not clear why the SF-36 sistance to antituberculosis medica-
more severely injured were referred to scores for the amputee group were tions.
Valley Forge. 109 Of these patients, 26 higher than those of the other groups. Philadelphia Naval Hospital and
were inju.red by land mines or booby One explanation might be the small Oakland Naval Hospital were respon-
traps. Otl1er mechanisms of injury in- number of patients. Another explana- sible for the treatment of a significant
cluded artillery/mortar fire (three pation might be the lower proportion of number of Navy and Marine Corps
tients) and machine gun fire (one pa- patients in the other groups that were amputees. Golbranson and associ-
tient). Indications for surgery were eligible to participate in the study. Fi- ates119 reported on ilie effectiveness
trauma in 53 (88%) of 60 residual nally, there could be an error in meili- of immediate postoperative fitting
limbs and infection in tl1e remaining odology. and early ambulation. While their dis-
seven. The medical records indicated Brown us studied bilateral lower cussion focused on older patients
that postoperative skin traction was extremity amputees at Fitzimmons with diabetes mellitus and immediate
used in fewer than half the patients. Army General Hospital. These pa- postoperative fitting, the implications
Three patients also sustained an upper tients had the most severe injuries, for the early fitting of young individ-
limb amputation, with one at the most often tlle result of explosive mu- uals with amputations due to trauma
wrist, one above tile elbow, and one nitions, and they often had other as- were significant.
below the elbow. Documentation of sociated injuries of the trunk, upper
shock and resuscitation attempts was limbs, and face. Because these ampu-
incomplete, but the records of 14 pa- tees did not have a sound leg available
Current Concepts
tients indicated that an average of 23. 7 for balance, they needed more time Mechanisms of Injury
units of blood had been transfused. for gait training. These patients were The injury leading to the eventual loss
Patients arrived at Valley Forge an fitted initially with shorter (stubby) of limb is worth investigating for sev-
average of 4.5 weeks after injury. prostheses and then advanced to reg- eral reasons. First, war wounds differ
Records of 23 patients showed that ular prostheses when acceptable gait from those seen in the civilian com-
they were fitted with pylons or stub- had been established. Brown empha- munity. Second, surgeons need to un-
bies an average of 8.3 weeks after in- sized return to recreational activities derstand disease processes to better
jury (range, 3 to 20 weeks). Records to help foster confidence, pride, and a treat the patient.

Land mines are the most common about 1 to 2 m. The device then ex- tion for severe injmies. Most amputa-
agent of wounding resulting in loss of plodes, causing multiple fragment tions (87%) are partial or complete
limb on the battlefield. The US Army wounds to persons nearby. trawnatic amputations, requiring
classifies land mines as antipersonnel Horizontal spray mines are devices only debridem ent of the residual
or antimaterial. Antimaterial land that fire fragments in one direction limb. Late amputations are the result
mines a1·e designed to destroy or dis- when detonated. The US Army's Clay- of infection or failed vascular re-
able vehicles. Antipersonnel land more mine, for example, fires about pair.1os
mines are meant to injure individuals. 700 steel balls weighing about 10
There are four general types of anti- grains each in one direction. Patients Late Amputations
personnel land mines: static, bound- tend to have multiple small fragment Recent interest has focused on deter-
ing, horizontal spray, and unconven- wounds from this injury. mining which limbs require amputa-
tional. Unconventional devices are land tion an d which fare best with limb
Static land mines are placed above mines or booby traps that are con- salvage. 121 - 133 Late amputations (ie,
ground or buried and remain in place structed of another piece of o rd- those that occurred after transport)
until detonated by a person who steps nance, such as a canno n shell or a gre- have been analyzed by several au-
on them. They generally have small nade. There can also be land mines or thors. Bagg, cited by Burkhalter, 103
explosive charges, 100 to 200 grams, booby traps made out of locally avail- reported that 13 of 200 tibia fractures
and are the most common antiper- able materials. Most amputations per- received at the 106th General Hospi-
sonnel land mines throughout the formed on US soldiers in Vietnam tal in Japan from Vietnam required
world. Surgeons from the fo rmer So- were caused by these devices. They are amputation (10 transtibial and 3
viet Union obtained considerable also the most common mine seen in transfemoral). Schmitt and Arm-
clinical experience with static antiper- Operation Iraqi Freedom. strong102 found that open fractures
sonnel land mines during the conflict with vascular injury were responsible
in Afghanistan from 1979 to 1988, Issues Affecting for nearly half (48%) of the late am-
which prompted laboratory investiga- Amputation putations seen in their facility during
t ions of the mechanism of injury. 120 the Vietnam War, followed by vascu-
They reported that small, static land Indications lar injuries alone (25%), fractures
mines created a very consistent pat- Amputations are performed in for- only (17%), and soft-tissue infection
tern of injury. Closest to the land ward hospitals to save lives, a goal (10%) .
m ine was an area of partial or com- that remains largely unchanged from
plete traumatic amputation (avulsion previous conflicts. Indications are Open Fractures
or mangling), usually at the midfoot partial or complete traumatic ampu- Open fractures have been classified
or distal tibia. Second, there was an tations that require only completion since the mid 1970s by the Gustilo
area of soft-tissue stripping from the of the residual limb, a major vascular and Anderson grading system (grade
bone or along fascia! planes resulting injury that cannot be repaired, or I, II, and III). T his system was later
from exploding munition. Tissue in overwhelming sepsis. modified to include grades IIIA, B,
this region, extending up to the knee, and C, depending on severity. Grade
may or may not survive. This area is Limb Salvage Versus IIIB fractures are open tibia fractures
critical in terms of tissue viability and Amputation that requii·e local or free flap coverage
ultimate limb length. }fore proxi- Every military surgeon should con- of the exposed bone. Grade IIIC frac-
mally, the effects of the blast itself aTe sider whether some limbs amputated tures have a vascular injury that re-
limited, though fast translation of the in previous conflicts could be sal- quires repair. Recently, Brun1back and
124
limb may occur. Fragments from the vaged today. To answer this question, Jones have raised concerns about
exploding munition, clothing, or de- the advances made in trauma care the interobserver reliability with the
bris may injure the contralateral limb over the years must be reviewed, par- classification system.
or other parts of the body. Factors ticularly their applicability to severely Caudle and Stern 125 reported on
that influence the injury from a par- traumatized limbs. Clearly, the ability amputation rates associated with 42
ticular land mine include the size and to repair a vascular injury has resulted type IIIB fractures that required a free
shape of the limb, which part of tl1e in an overall reduction in the number flap and 9 type IIIC fractures with re-
foot first touches the land mine, the of amputations because vascular re- pairable vascular injury. Of the pa-
type of footwear worn, and the pair was widely attempted during the tients with IIIB fractures, 17% re-
amount of debris overlying the land Korean War. Since Vietnam, the use of quired amputation, compared with
mine. free flaps to cover bone defects has 78% of patients with type me frac-
Bounding mines are land mines prevented infection and improved tures.
that, when tripped, propel a small de- healing. New designs in external fixa- Georgiadis and associates 126 eval-
vice such as a grenade vertically to tion have improved fracture stabiliza- uated patients with 20 severe tibia

fractures that required a free flap for tively high specificity and thus could in Pakistan, recommending delayed
soft-tissue coverage. Of these, only not be recommended as criteria to primary closure of the transtibial am-
four required amp utation. Average amputate a limb. Thus far, it appears putations that result from war
follow-up was 35 months. Another 18 that no scale can reliability predict the wounds. The patients' in this series
patients w ith severe tibia fractures outcome of a severely traumatized survived a median transport time to
seen at this facility at the same time lirnb. the hospital of 14 hours; the more se-
required primary amputations. Aver- It is not clear, therefore, if the new verely injured patients in my series
age follow- up for this group was 44 techniques developed since the Viet- would not have survived that long an
months. Two patients in the limb sal- nam War will improve limb survival evacuation time. In Simper's study,
vage group had major vascular injury, and function for patients injured on delayed primary closure of the resid-
whereas 15 of the 18 amputees had the battlefield. ual limbs was performed a median of
vascular injuries. Three patients in 6.4 days from the initial surgery. A to-
the limb salvage group returned to Vascular Repair Failure and tal of 13% of the amputations in this
work, compared with 9 of the 18 am- Amputation series failed .. There was no discussion
putees. Average time to full weight Vascular repair has been used since of prosthesis fitting.
bearing was 13 months for the limb the Korean War. Open fractures with The treatment of refugees in a the-
salvage group and 6 months for the associated vascular injury can be ater of operations or in " nation build-
amputation group. treated by fracture stabilization fol- ing" efforts remains dependent on the
Quirke and associates 127 evaluated lowed by vascular repair. Use of exter- resources available to the medical
35 patients with open tibia fractures nal fixators is indicated to provide ac- staff. Surgeons treating refugees
and major vascular injuries (Gustilo cess to the vascular structures of the should not plan procedmes that re-
type IIIC). Of these, 21 underwent limb. Using local or free flaps for soft- quire extensive long-term care. Proce-
primary amputation (60% ) and 14 tissue coverage should never be at- dures should be planned with the
(40%) required vascular repair and tempted in theater unless the patient country's resources in mind, not what
fracture stabilization. One underwent is fo llowed through healing by the is possible at a medical center in the
late amputation. same surgeon at the same location. United States. In this context, the rec-
Patients who are to be evacuated ommendations by the ICRC are rea-
Predicting the Need for should not undergo extensive surgery sonable and can be used to provide
Amputations for soft-tissue coverage before evacua- the best care fo r the most people. Pa-
Attempts to predict the need to am- tion. Attempts at coverage should be tients in this setting can be cared for
putate have resulted in the develop- performed only when a patient is in a by the same surgeon and do not have
ment of several limb salvage scores. stable environment and will not be to be evacuated. Fitti ng of amputees
The mangled extremity severity score moved. 133 is often problematic because prosthe-
(MESS), NISSSA (N=Nerve injury, ses are expensive and rehabilitation
I=Ischemia, S=Soft-tissue mJury, Initial Management requires additional resources. 134"137
S=Skeletal injury, S=Shock, and Refugee Care
A= Age), Predictive Salvage Index Recent experience in treating civilian Care of US or Allied Soldiers
(PSI), and Limb Salvage Index (LSI) war casualties by the International As reported previously, the US Army
have been evaluated in a few studies Committee of the Red Cross (ICRC) established an amputee service at Val-
characterized by small sample sizes has led to guidelines on the care of ley Forge Army General Hospital in
and a wide range of injuries (Gustilo amputees in strife-torn regions 1969 to care for the increasing num-
types IIIB and IIIC) .121-123,131 throughout the world. Initial surgical ber of amputees d uring the Vietnam
Bosse and associates 123 •131 enrolled management consists of excising dead War. 108•109· 113 As referenced earlier,
601 patients prospectively in the tissue, fashio ning flaps that can be LaNoue reported on a group of trans-
LEAP (Lower fa..1:remity Assessment closed later, and placing the limb in a tibial amputees who were treated at
Project) study group, which evaluated bulky dressing. The wound is in- VaUey Forge Army General Hospital
the MESS, the NISSSA score, the PSI, spected in the operating room a few and compared those whose wounds
the Hannover Fracture Scale-97, and days later and is closed if the wound were closed in theater to those whose
the LSI. In this study, there were 55 condition permits. Patients may be wounds were left open and main-
traumatic amputations, 63 immediate fitted with a prosthesis when the retained in skin traction. He examined
amputations, and 86 delayed amputa- siduaJ limb wound is healed and the 230 patients with transtibial residual
tions. The authors reported that none edema bas subsided. No discussion of limbs, some of whom were multiple
of the scales was sufficiently predic- early fitting of amputees is presented amputees, and reported that 41% of
tive in determining when amputation in ICRC literature. 134"137 patients underwent wound closure in
is necessary. Threshold scores were Simper 134 recently reported on the theater. Of those closed in theater,
found to have low sensitivity but rela- treatment of 111 transtibial amputees 56% experienced failure because of

gross infection. Time to permanent Transtibial Amputees Patients arm cast is then applied, using 4-in
prostheses was also longer for patients with transtibial amputations should cotton padding and 4-in wide plaster.
whose wounds were closed in theater be placed in a modified long leg cast. An outrigger is applied so that about
( 13 months) compared with those During the last surgery in theater, a 1 kg of traction can be maintained.
whose residual limb was left open (11 dressing should be placed over the The cast must be bivalved before
months). wound and then the cast applied. The evacuation.
LaNoue indicated that skin trac- cast consists of 6-in wide plaster and Transhumeral Amputees Trans-
tion was essential to prevent compli- 6-in cotton padding. The end of the humeraI amputees can be placed in
cations, especially in patients placed residual limb is cleaned, and an ad- traction by applying a dressing to the
on an airplane to reach the site of de- herent is applied to the skin. Stocki- end of the residual limb. Stockinette
finitive care. Skin traction is used to nette is applied over the distal end of can be applied over the end of the re-
preserve residual limb length and pre- the residual limb for about the last sidual limb only but is usually applied
vent infection. 10 to 15 cm, and the cast is applied to the entire length of the residual
Recommendations for US or Allied from the end of the residual limb to limb. After padding, a wire splint can
soldiers who must be evacuated from the proxin1al thigh. An outrigger, be fashioned and placed over the dis-
theater are unchanged since the Viet- made of a wire (ladder) splint, is used tal end of the residual limb. It can
nam War. Surgery should be per- to maintain traction. For transtibiaI then be held in place by plaster of
formed at the lowest viable level of amputees, traction should be from Paris. If the wound is proximal, this
soft tissue with no consideration of 1 to 2 kg to overcome the elastic recoil technique may not be possible with-
the definitive or final level of amputa- of the skin. The cast should be bi- out making a shoulder spica cast (AM
tion. The open circular technique, valved before air evacuation. 108 LaNoue, MD, Ft. Leavenworth, KS,
which has since been renamed open Transfemoral Amputees Trans- unpublished data, 1971 ).
length-preserving amputation, should femoral amputees should be fitted
be used with stepwise shortening at with a hip spica cast, which is best ap- Definitive Management
levels from the skin to the bone, with plied during the last surgery in the- Upon arrival from overseas, patients
the skin the most distal and bone ater. A fracture table can assist the ap- should be carefully examined by a
most proximal. All dead or necrotic plication of the cast. Stockinette is team of surgeons, therapists, and
tissue should be removed. Often with applied to the distal end of the resid- nurses. Open residual limbs should be
irregular war wow1ds an oblique ual limb, similar to transtibial ampu- examined and placed in skin traction
wound is created. Wounds should be tees, after a dressing is placed over the to prevent bony protrusion. Once ex-
left open because it is safer for pa- wound. The sacrum and anterior su- amined, lower limb amputees should
tients evacuated by air. These wounds perior iliac spine (ASIS) are padded be fitted with a provisional prosthesis
should be placed in skin traction to with felt. Six-inch cotton padding is as soon as possible, even if they have
prevent bone protrusion and residual placed from the distal end of the re- open wounds. This prosthesis should
limb swelling. Patients should be sidual limb to the level of the umbili- be removable to allow access to the
placed in transportation casts before cus, and the contralateral thigh is in- wound and skin traction in bed.
air evacuation. cluded. Next, 6-in plaster strips are Clearly, early walking has psychologi-
wrapped, beginning with the involved cal benefits, improves wound healing,
Transportation Casts limb. An outrigger must be incorpo- and allows earlier propriocep-
Transportation casts sboµld -be used rated to the distal end to provide traction 108· 109•113 (AM LaNoue, MD, Ft.
for patients who are to be removed tion through the stockinette. The Leavenworth, KS, unpublished data,
from combat zone hospitals because traction should be from 2 to 4 kg, 1971 ). Upper limb amputees also re-
these casts provide continuous, porta- enough to overcome the elastic recoil quire thorough examination and
ble traction throughout the evacua- of the skin. For the last roll, the cot- placement in a provisional prosthesis
tion chain. Lower limb amputees often ton padding is turned down to the to begin training in activities of daily
can ambulate on crutches if the ampu- level of the ASIS. In this way, the living. This training should begin
tation is an isolated injury, but they completed cast leaves the abdomen daily under the supervision of occu-
should be considered litter patients. exposed, which allows respiratory pational therapists. 138
Traction can be attached to the litter or function during transport. The cast
a traction splint used; however, neither should be bivalved before evacua- lower limb Amputees
provides reliable traction that can be tion.1os,113 Transfemoral amputees received from
maintained throughout the evacua- Transradial Amputees Transra- overseas should be placed in skin
tion chain. In addition, no soft-tissue dial amputees are placed in skin trac- traction upon arrival at the hospital
support is provided by these means tion by applying a dressing over the in the United States. A provisional
(AM LaNoue, MD, Ft. Leavenworth, wound and then stockinette i11 the prosthesis (pylon) should be fabri-
KS, unpublished data, 1971 ). manner previously described. A long cated with a plaster socket, a shank,

and a foot. Patients should not receive for young patients who sustain trau- Postoperatively, the patient is
a knee until some gait control and matic amputations because it pro- placed in a cast with a walking heel to
progress in healing are made. A knee vides a more durable residual limb. begin ambulation. As ambulation im-
may increase the shear forces across Deffer and associates110 and Deffer 111 proves and swelling decreases, the cast
the open wound. reported good results with the use of should be changed. Once the swelling
As the edema and swelling subside, this technique on Vietnam War trans- and edema have reached a plateau,
the patient may be fitted with a knee, tibial amputees. However, no study the patient can be fitted witll a per-
and therapy should be d irected to- compares patients treated with the manent prosthesis. Prosthetic consid-
ward establishing normal gait. In- procedure with those who were erations include the use of a foot with
creasing weight bearing decreases not.1os,1 10,111 limited height so that limb lengthen-
edema. As the wound heals, it should If a secondary procedure is per- ing does not occur, resulting in limb-
be assessed periodically to determine formed, the patient can be fitted on length discrepancy. A iliinner solid
whether additional surgery is indi- the operating table with a pylon that ankle-cushion heel (SACH) foot has
cated. Coverage obtained by skin trac- can be left on for 2 weeks, and gait been the ch~ice for this type of am-
tion alone often results in a distal scar training can be resumed immediately. putation, along witJ1 a double-walled
or adherent tissue to the bone. Myo- The prosthesis can be removed earlier prosthesis witll an elastic liner.
desis can be considered if the patient's in the event of drainage, pain, or loos-
condition is stable in the weeks after Upper limb Amputees
ening. The pylon is then changed
injury, if the patient has begun ambu- When deemed stable, the patient is
weekly until the edema and swelling
lation, and if swelling and edema in placed in skin traction witll a trans-
have subsided. The patient can then
the residual limb are decreased. Al- portation cast before evacuation to.
be fitted with a permanent prosthesis.
though there is no "ideal length," the United States. Prior to application
Syme Ankle Disarticulation
limbs less than 10 cm distally from of the cast, stockinette is applied to
Syme ankle disarticulation is the
the greater trochanter are more diffi- the last 15 cm of the skin by means of
highest level of amputation a patient
cult to fit . During the planned second a skin adherent. For a transradial am-
can have without wearing a prosthesis
procedure, the adductor and quadri- putee, tlle cast consists of a long arm
for limited ambulation. This proce-
ceps may be attached to the distal end cast with an outrigger made of a lad-
dure should not be performed in the-
of the femur to prevent the potential der wire splint or similar device. Skin
ater because the vascular supply to
for abduction contracture. traction, sufficient to overcome the
the heel pad can easily be compro-
After the second procedure is com- elastic recoil of the skin, is applied to
mised when left open. LaNoue re-
plete, the patient may be fitted with a the stockinette covering the distal end
ported that 88% of tJ1ese procedures of the residual limb. The cast must be
pylon and allowed to ambulate care-
performed in theater failed because of bivalved before evacuation . 132
fully, paying attention to pain and
sepsis. Forefoot injuries without a Transhumeral amputees are best
drainage in the residual limb. This py-
compromised heel pad should be served by a shoulder spica cast, which
lon should be replaced frequently as
the edema and swelling subside. A pa- debrided, and the patient evacuated allows an outrigger to be placed to
tient with a well-healed residual limb from theater. A Syme procedure apply traction as indicated above.
of a stable size may be fitted with a should be performed only at the site However, in multiple-trauma patients
permanent prosthesis, typically 6 to of definitive care (AM LaNoue, MD, with chest injuries, a shoulder spica
8 weeks later in healthy young adults. Ft. Leavenworth, KS, unpublished cast may not be possible and should
Unilateral transfemoral amputees data, 1971). be replaced with a padded coaptation
treated at Valley Forge Army General The Syme ankle disarticulation is splint with a wire splint s uch as an
Hospital were ready for a permanent performed by creating a heel flap and outrigger. 137
prosthesis about 7 months after in- removing the talus and calcaneus. The Shoulder disarticulation is a rare
jury (AM LaNoue, MD, unpublished tendons are cut and allowed to re- level of injw-y. Skin traction may not
data, Ft. Leavenworth, KS, 1971). Very tract. Major vascular structures are li- be possible because of other injuries,
short residual limbs can be salvaged gated and then cut. Because small ves- but the wounds should be left open
using a small pin fixator and length- sels tend to nm witll the nerve, they during evacuation.
ening of the bone. The quality of the should be ligated and tJ1en allowed to Once at the site of definitive care,
regenerated bone and skin should be retract to prevent neuroma forma- patients should be thoroughly exam-
observed. tion. If the procedure is performed in ined. All wounds should be uncovered
The Ertl Procedure The Ertl pro- one stage, the malleoli and articular and inspected. The upper limb ampu-
cedure provides a more end-bearing surface of the distal tibia are removed tee can be placed in a provisional
residual limb by creating a bone to form the residual Limb. The heel prosthesis while maintaining skin
bridge beween the distal tibia and fib - flap is brought forward to cover the traction and can begin to learn to
ula. This procedure is recommended distal end of tlle residual limb. perform activities of daily living.

94 Section I: Introdu ction
Casts should be changed until the in skin traction to prevent infection 6. Detmold W: Lectures on military sur-
edema and swelling have subsided. At and loss of resid ual limb length. gery: Lecture VII. Am Med Times 1863;
this point, a second procedure may be As was demonstrated in previous 6:73-74.
performed to close the residual limb. conflicts, th ere is a clear need for am- 7. Peters DC: Remarks on amputations.
Usu ally, a plastic closure is performed putee centers that specialize in the Am Med Times 1863;6:302-304.
to remove adherent scar and close the care of soldiers evacuated from a the- 8. Smith DP: Experiences in military
woun d . Sometimes bone will be ater of operations. The main advan- surgery. Am Med Times 1863;6: I 10-
sh ortened to obtain wound closure. tages of this consolidation of efforts 111.
Patients who were injured while were described in this chapter; they 9. Fisher GJ: Report of fifty-seven cases
holding an explosive device may have include maintaining the clinical skills of amputations in the hospitals near
bilateral amputations and be partially of t he nursing staff, prosthetists, ther- Sharpsburg, MD, after the Battle of
or completely blind. Of these patients, Antietam, September 17, 1862. Am J
apists, and surgeons to facilitate com-
Med Sci 1863;XLV:44-51.
transradial amputees may benefit plete healing of the residual limb; fit-
from the Krukenberg procedure, 10. Letterman J: Medical Recollections of
ting with a provisional prosthesis;
the Army of the Potomac. New York, NY,
which involves separating the radius rehabilitation; and fittin g with a satis-
Appleton and Company, 1866.
and ulna to create a pincers mecha- factory permanent prosthesis.
nism. The pronator teres provides the 11. Oblensky FE: Jonathan Letterman. Mil
The US military has established an
Med 1968;133:312-316.
strongest adduction force in this pro- amputee cen ter at Walter Reed Army
cedure. This type of amputation does 12. Jones GW: The medical history of the
Medical Center, and clinical experi-
Fredericksburg Campaign: Course and
not preclude the use of a standard ence in treating battle amputees is in-
significance. J His Med l 963;XVII1:
prosthesis. 130 creasing. Clinical experience can be 241-256.
Patients with a shoulder disarticu- obtained by working in amputee clin-
13. Gibbs OC: Correspondence-
lation should undergo skin closure ics at Veterans Administration hospi- Amputations at the Battlefield of Fre-
when the soft tissues will tolerate it. tals, but it does not provide experi- dericksburg. Med Surg Report 1863;9:
T hey can be fitted with a permanent ence with the initial care and 416-418.
prosthesis as soon as the wound is management of this special group of 14. Moses I: Surgical notes of cases of
healed. amputees. Care provided to refugees gunshot injuries occurring near Chat-
throughout the world by the ICRC tanooga, Tennessee. Am J Med Sci
and other organizations provides
Conclusion 1863;18:311-366.
some experience for the initial care of 15. Hodgen JT: On the treatment of gun-
Amputations are the most severe limb battle amputees, but there are differ- shot fractures of the femur and tibia.
injuries seen in war. Care for ampu- en ces in amputee care because a refu- Am Med Times 1863;8:169- 170.
tees has been a significant clinical gee will not be evacu ated out of the 16. Lidell JA: Correspondence. Am Med
concern for the military in every ma- coun try. Times 1863;8:102-103.
jor conflict in the 20th cen tury. As few
17. Hamilton FH: A Treatise on Military
surgeons or teams have significant Surgery. New York, NY, Bailleire Broth-
clinical experience in caring for am- References ers, 1865, p 420-486.
putees, lapses or inconsistencies oc- l. MacLeod GHB: No tes on the Surgery of
l8. Otis GA, Huntington DC: The Medical
cur. Furthermore, the techniques and the War in the Crimea With Remarks on
and Surgical History of the War of the
requirements for patients who are the Treatment of Gunshot Wounds. Phil- Rebellion: Part II. Washington, DC,
evacuated from overseas hospitals dif- adelphia, PA, JB Lippincott, 1862. Government Printing Office, 1883, vol
fer from those required by patients 2. Gross SD: A Manual of Military Sur- 2, pp 1-614, 870-871.
treated in civilian hospitals. War surgery. Philadelphia, PA, JB Lippincott, 19. Jewett CC: After-treatment of amputa-
- -~~\\r.£~,_...,,
"'41
1,)~uvia.., hrrrr-,ar,,,-J.---...,..,1861, DD 7_4-89. Re rinted b Nor-
r -- ·- C>Y,4lS:~.:ffi • OffCI'..-..~.......--~-'"·-,
_th
___ --~-i=rr..tt,rn,1lu 1i, 'ai1 h aut.n,1:.6, 1....rt,
Corps Field Hospital after Gettysburg.
- ·----- procedure. Initial care
emove e l 988 _)
td save the . . Boston Med Surg J 1864;70:211-216. limb to p revent infecti
3. Hamilton PH: A Practical Treatise on
a forward patient's life is provide
Military Surgery. New York, NY, 20. Minor JM: Report on artificial limbs.
~putations Bailliere Brothers, 1861, pp 165-189. New YorkAcadMed 1861;1:163-180. hospital. Most forwar
r complete (Repri nted by Norman Publishing, 21. Goldthwait JE: The Division of Ortho- simply complete a par
ce stabi- San Francisco, CA, 1989.) paedic Surgery in theAEF. Norwood, traumatic amputatio
placed in 4. Warren E: An Epitome of Practical Sur- MA, Plimpton Press, 1941. lized, the patieot sho
skin trac- gery for Field and Hospital. Richmond, 22. Goldthwait JE: The place of orthope- a transportation cast
nless the VA, 1863. (Reprinted by Norman Pub- die surgery in the treatment of war tion for transportatic
:>atient for lishing, San Francisco, CA, 1989.) casualties. Mil Surg 1917;41:450-456. surgeon is able to follo
y pJv. t hP ~ <:::,.r;.-.l._,,.."o r. A d"" 'J\.(orl
n"ll""l,U+~t; l'\n<' ?~ R l">lrP TA. l=-2rh, PVl"IPriPnrPC in thP Uf"ll"
vcdftrfA~ r-O@~bn~W~{
woano m~s oe ,err-open anb p1ate . . ·rnit.n1ibj;b\'l49'.,:f:5u. .,..~.:&- ~<" f ,...,. rprM,£MnS~rgl919~:62~63

~U LXll t:Jllll Y -~ e- ea)1fa)11\JWdll(Jit.J..t'\.1!.! ~ ,!;vu.;_cpCUl" •; - ; • • ~· •\ eh kro'i,;ot., YV I LIO, f,!°~, ._~_ru,{L~\~~t: IOSi. • •• I uJhuu u, l
S). J Orthop amputee rehabilitation. Clin Orthop J BoneJointSurgAm 1993;75:l431- Severity Sc

7. 1968:56:119-131. 1441. Trauma 19
Dl<, Beasley W, 120. Nechaev EA, Grisanov AI, Fomin NF, 127. Quirke TE, Sharma PK, Boss WK, 133. McNamar,
injury in Viet- Minnullin IP: Mine Blast Trauma: Oppenheim WC, Rauscher GE: Are Wright JK:
ies. Ann Surg Experience from the War in Afghani- type IIIC lower extremity injuries an nam comt
stan. Stockholm, Sweden, Faiths Try- indication for primary amputation? 1973;178:l
ial amputation in ckeri, 1995 [In Russian ). J Trauma 1996;40:992-996. 134. Simper LB
w of 111 ampu- 121. Bondurant FJ, Cotler HB, Buckle R, 128. Lange RH, Bach AW, Hansen ST Jr, et war surge,
primary closure. et al: The medical and economic imal: Open tibia fractures with associ- tations wi1
-98. pact of severely injured lower ex- ated vascular injuries: Prognosis for /Trauma I
utations for War tremities. J Trauma 1988;28: 1270- limb salvage. J Trauma 1985;25:203- 135. Coupland
itzerland, Inter- 1273. 208. Wounds. G
- - -·-··._..· ... ""-' ,, 11,.,1\o.t11v1 a1 a111putc.c:,
._·_ _..,._•• L ... ' p: _,_ · - '"'-- ~r·.·-,1.-..~a~c...., ..,,.

, ,r:111 I," , r-f'1 ("\f"
L,
Tl
,,.._,I , ,-- I .... I I A 00 ,,-..._ I I I t , ... 1 .... 1
Chapter 8: Kinesiology and Functional Characteristics of the Upper Limb 103
9(f -
Figure 7 A, Elevation of the upper limb

from 0° to 180°. From 0° to 30°, the mo-
tion is mostly glenohumeral (GH), with
llatural elevation of the upper scapulothoracic (ST) motion occurring to
e coronal plane involves 90° of a variable degree. Overall, the ratio be-
104 Section II: The Upper Limb
150
140
130
120
110
", .,
100
-~
c 80
\' / .I
::, 70
\,...Y·
-··-··
v
<
c
-~ti 60
50
.
_~
..........
\ '\'\..,.....
......... '\
the scapulo-
40
30
20
"·'·~ Figure 10 Elevators
I plane. 1 = midhumeral joint in the cc
natus, 3 = in- 10 die deltoid, 2 = sui
minor. The fraspinatus, 4 =
0 subscapularis, which
anteriorly and 90 100 110 120 130 180
w, is also an el- Degrees of elevation of the arm cannot be seen on th
evator.
Fiotl!P 11 FM(; r1rtivitv of thp PIPvrltor~ .:'It thP ~rr1n11lnh11mPrr1I inint in thP rnroi:>.a.L . - ~ - - - - - L - - - - -
:I holds a maxi- plane. A ll five muscles are active from 0° to 90°. Beyond 110°, the c
The infraspina- mum level of activity. The supraspinatus decreases in activity after ·
3lf of elevation tus and teres minor maintain high levels of activity during the seco
~ith permission to ensure necessary external rotation of the shoulder. (Reproduc
j' the shoulder from Inman VT, Saunders M, Abbott LC: Observations on the funa
joint. J Bone Joint Surg 1944;26:1-30.)
and beyond this point its activity di- lower and inner qu,
minishes and traces a sine wave. The ~ope of action E1, j
m II: The Upper Limb 106
~nem: Of ute _.... lUldll!> IIIIIIVI. __ _
ure 25 In the horizontal plane, the Figure 26 Rotation at the scapulohumeral joint. A, With the arm in neutral elevation,
can achieve 140° of flexion and 45° external rotation of 100° and internal rotation of 70° is possible. B, With the arm ele-
extension. vated 90°, external rotation of 90° and internal rotation of 70° is possible.
Elbow
The elbow joint determines an arc of
motion, ~. with a range from 0° to
150°. The orientation of the plane of
action is closely influenced by the ro-
+++ tational position of the shoulder
Brachlalls ++ ++ ++ joint. For example, when the arm is
elevated in the coronal plane, the en-
+ +++ velope of action ~ of the elbow is lo-
++ ++ cated in this plane if the shoulder is in
external or internal rotation.
Brachioradlalls
+ + + ++ Although the motion of the elbow
has been classified as a hinge joint, its
motion is better described as a loose
ure 27 Muscle activity during elbow flexion. (1) Flexion in supination without resis- hinge. The instant center of rotation
nce: (2) ~lovlnn1 in no11tral with'),rt roeirt?""9' f~\'il<>vi~JD..'X'lW''"' ,.,i.hn,rt r<>eie- va1'~Pc th1'nnat,nnt th .. <11'r nf fl-,vinn - _ 1
c- tance; (4) Flexion in supination with resistance. The brachialis is the baseline flexor. The extension. Because this varia
biceps is the reserve flexor. Its action is decreased in pronation but increased when the
curs over a small area, it is co
d 'forearm is supine, especially when resistance is encountered. Its action is decreased in
=
pronation. The brachioradialis is more active against resistance. +++ maximum activity, a single axis of rotation,
= =
++ mild activity, + minimal activity. through the center of the arcs
by the trochlear sulcus and
tellum. Using external landm
The infraspinatus is responsible Internal rotation of the humerus is corresponds to a line passing
primarily for external rotation of the produced by the combined action of the inferior aspect of the me
humerus (Figure 12), with varying the pectoralis major, latissimus dorsi, condyle and the center of th
degrees of assistance provided by the teres major, and subscapularis (Figure epicondyle.7
teres minor an~ posterior deltoid de- 12}. As abduction of the arm in- The main flexors of the el
a- pending on the position of the arm. creases from 0° to 90°, activity of the the brachialis, biceps, and br
a As the arm is abducted, the posterior subscapularis, pectoralis major, and dialis. Intricate interactions
C- deltoid becomes more important, ac- latissimus dorsi tends to decrease, wide range of participation
e- counting for 60% of the strength in whereas activity of the deltoid in- complished by the elbow fla
e- 90° of abduction.6 creases.6 pending on the position of

Chap ter 8: Kinesiology and Functional Characteriistics of the Upper Limb 109
Figure 28 Rotation at the distal radio- - - - -11. 1·

ulnar joint. In habitual rot ation, t he axis
passes through the middle of the distal
end of t he ra dius (+). From supinati on t o
pronation, t he rad ial styloid t races curve
1 and the head of the ulna t races curve 2.
15.6 15
From supination (S) to neutral (N), the
head of the ulna is extended and laterally
10
displaced. From neutral (N) t o pronation
(P), it is f lexed and f urther laterally dis-
placed. When t he axis of motion passes 5 - - - - ---
through t he center of t he ulnar head, the
latter stays still during rotation, whereas
the radial styloid traces a very large curve 9 0° Pro natio n N eutral 90° Supinatio n
(3). The location of the axis of rotation is
determined by a peripheral point of fixa - Figure 29 Radiohumeral interosseous distance in pronation, neutral, and supination.
tion. The distance is maximal in neutral and minimal in pronation. (Adapted with permission
from Christensen 18, Adams JP, Cho KO, et al: A study of the interosseous distance be-
tween the radius and ulna during rotation of the forearm. Anat Rec 1968;160:261-27 1.)
arm, degree of elbow flexio n, and the
applied load.8 •9 The brachialis is the
"workhorse" flexor and is active at creased load. Contrary to previous ure 28). Proximally, the axis passes
any rotational position of the fore- studies, 10 the different heads of the throug!b the capitellum and the con-
arm, any degree of elbow flexion, and triceps generally are active in a similar cave center of the radial head. Dis-
with or without load applied to the manner throughout motion. tally, it passes somewhere between the
flexing forearm (Figure 27). Because radial and ulnar styloids. When the
of the insertion of the brachialis on uln a is fixed in position, such as when
Forearm the forearm and hand are resting on
the ulna, there is no influence on ac-
tivity with forearm rotation. The bi- Forearm rotation occurs about the their ulnar border, the longitudinal
ceps is also active throughout a full proximal and distal radioulnar joints, axis of pronation-supination passes
range of elbow flexion; however, its with the radius rotating around the through the concave center of the ra-
activity decreases during forearm pro- ulna. Rotation of the ulna with re- dial head proximally and near the
nation. The greatest biceps activity spect to the humerus is also coupled fovea of the distal ulna distally. 12 This
Ch apter 8: KinesioJogy and Functional Characteristics of the Upper Limb 111
1 2 3
3
~ ~ ~
.
Supinator ++ ++ +++
Biceps + +
- +++
Figure 33 Supination of the forearm. (1) Supination with the elbow flexed without re-
sistance; (2) supination with the elbow extended without. resistance; (3) supination
against resistance. +++ = maximum activity, ++ = mild activity, + = minimal activity,
-= no activity. The supinator is t he main supinator. The biceps is the reserve supinator,
functioning best with the elbow flexed 90° or when speed or power is req uired.
utes 34%, with the remammg 66% pollicis brevis. The ulnar deviators are
contributed by the radiocarpal joint 17 the extensor carpi ulnaris and flexor
(Figure 35). carpi u lnaris, with the extensor carpi
Figure 32 Supinators of the forearm. The wrist flexors are the flexor ulnar is becoming more effective with
(1) Supinator, main supinator; (2) biceps, carpi radialis and ulnaris and the pal- forearm pronation.
reserve supinator; (3) extensor carpi radi-
maris Jongus. The long digital flexors The degree of participation of the
alis Jongus and brevis, questionable ac-
cessory supinators. The arrow indicates are accessory flexors at the wrist. The digital motors determines recruit-
supination. wrist extensors are the extensor carpi ment of the wrist motors. When the
radia.lis longus and brevis and the ex- wrist is in extension and the fingers
tensor carpi ulnaris. The digital ex- make a soft fist, the following wrist
ulnar deviation, the center of rotation
tensors are tl1e accessory extensors of motors are active in descending order:
is in the head of the capitate.
the wrist. extensor carpi radialis brevis, exten-
Overall, the average range of wrist
Lateral motion at the wrist aver- sor carpi ulnaris, and extensor carpi
flexion and extension is 75° to 90°.
ages 15° to 25° of radial deviation and radialis longus. With a tight fist, all
Through the flexion-extension arc,
25° to 40° of ulnar deviation. With three extensors are maximally active 18
the proximal and distal rows move in
radial-ulnar deviation, the two carpal (Figure 36). When the fingers are gen-
similar directions. Wrist flexion,
rows demonstrate reciprocating mo- tly extended and the wrist is held in
which produces flexion and ulnar de-
viation of both rows, and extension, tion with the proximal carpal row extension, the extensor carpi ulnaris
which produces extension and radial sliding in the direction opposite of and flexor carpi ulnaris are active.
deviation, generates an overall cou- hand movement. During radial devia- The fo1·ceful opening of the fingers
pled wrist motion of flexion-ulnar tion, motion occurs primarily at the brings into action, in descending or-
deviation and extension-radial devia- midcarpal joint, with the distal row der, the following additional wrist
tion. Flexion-extension is motored by extending, deviating radially, and motors: extensor carpi radiaJis brevis,
the pull of the extrinsic flexor and ex- translating from a dorsal to palmar palmaris longus, extensor carpi radia-
tensor muscles on the metacarpal direction. The proximal row flexes lis longus, and flexor carpi radialis 18
bases. The distal carpal row is pulled and displaces to a less pronounced (Figure 37). Grip strength is maximal
in a similar direction because of the degree in an ulnar direction. During with the wrist in 35° of extension and
secure association of the metacarpal ulnar deviation, motion occurs at 7° of ulnar deviation and is signifi-
bases to the distal carpal at the second both the intercarpal and radioearpal cantly reduced when the wrist devi-
through fifth carpometacarpal joints. joints. The distal row flexes and devi- ates from this posit~on. 13
The proximal carpal row follows be- ates ulnarly whereas the proximal row
cause of articular contact and liga- extends and moves radially at the ra-
mentous attachments to the distal diocarpal joint. Hand
row. Overall, the midcarpal joint con- The radial deviators of the wrist Fingers
tributes 60% of the arc of flexion and are the extensor carpi radialis longus Located at the end of a multiseg-
the radiocarpal joint contributes 40%. and brevis, flexor carpi radialis, ab- mented system, the hand functions
In extension, the midcarpal contrib- ductor oollicis longus, and extensor within the action enve.lone. F., of thP
112 Section Il: The Upper Limb
Pronotion
Extension
A B Supinotion c Pronation
I
fictu re 34 A. Fi Ld 0Lfno1i9n nf t,be..,.wrist aor t h;:rnrl w h PrP F. i~ the ;iction envelooe of the wrist an.d E, is t he action envelooe of the
1 1
aci~~ arl equiangular Spiral. Toe t1eld ot mot ion ot the Tinger 1s w1tnin t 3 wnen tne wnst 1s extenaea ana proJecrs prox1ma11y
I
1e w rist is flexed. B, The extended wrist , when rotated, explores t he outer half of a circle that is the base of sphero id E3 . C, The
vrist, when rotated, explores the inner half of a circle that is t he base of spheroid E3 .
lope E3. With wrist flexion, the action A fine mechanism of coordination
envelope E4 of the fingers extends be- is present locally in the fingers at the
yond the field of motion of the wrist level of the interphalangeal joints as
(Figure 34). initially presented by Landsmeer20
With prehension of the fingers, the (Figure 38). Finger flexion is initiated
interphalangeal and metacarpopha- at the level of the distal interpha-
langeal joints must flex in a coordi- langeal joint by the flexor digitorum
nated fashion to permit wrapping of profundus. As the distal interpha-
the digital palmar surface over the langeal joint flexes, the terminal ten-
surface of the object. Separately, the don is displaced distally, causing dis-
distal joint is flexed by the flexor pro- tal movement of the extensor
fundus, the middle joint by the flexor trifurcation through pull of the lateral
superficialis, and the metacarpopha- slips, resulting in relaxation of the
langeal joint by the intrinsic muscles. central slip. Simultaneously, the ob-
The coordination of flexion at the in- lique retinacular Hgament attached to
terpbalangeal and the metacarpopha- the terminal tendon also increases in
langeal joints is brought about by the tension and, passing volar to the axis
instantaneous participation of the of the proximal interphalangeal joint,
35 Contributi on of the radiocar- extrinsic-intrinsic motors command- automatically flexes the middle pha- Fi~
d midcarpal joints to flexion- ed by the motor cortex as well as lanx. This is a passive mechanism of pa
>n. A, For f lexion, 60% is midcar- ex
through passive restraints. This pas- interphalangeal joint motion. When
d 40% is radiocarpal. B, For pa
>n, 33.5% is midcarpal and 66.4% sive restraint is primarily the result of the proximal interphalangeal joint is ex
carpal. (Reproduced with permis- the oblique retinacular ligament that flexed approximately 70°, the previ- is
m Sarrafian SK, Melamed JL, Gos- arises from the palmar aspect of the ously relaxed central slip develops sic
GM: Study of wrist motion in proximal phalanx and adjacent flexor tension, pulling the extensor trifurca- hg
and extension. Clin Orthop 1977; fie
sheath, passing volar to the proximal tion farther distally, relaxing the lat- 12
'-159.)
interpbalangeal joint, lateral to the eral slips, lateral conjoined tendon,
middle phalanx, and dorsal to the dis- and terminal tendon. This unloading
rhe flexing finger traces an ac- tal interphalangeal joint, inserting of the terminal tendon allows for WI
!Velope, E4, that is an equiangu- into the distal extensor hood. This lig- complete flexion of the distal inter- tic
,ral19 (Figure 34). When the ament coordinates flexion and exten- phalangeal joint without encounter- la1
; extended, the field of motion sion at the proximal interphalangeal ing resistance from the extensor ten- Wl
fingers is within the wrist enve- and distal interphalangeal joints. don. Any break in this system of 0
an Academy of Orthopaedic Surgeons A1

activation and coordination interferes

with the function of prehension. 1 2
The absence of intrinsic muscle ac-
tion not only breaks the contour of
the longitudinal arch of the finger but
also creates an abnormal pattern of
function. The three joints flex succes-
3 3
Extensor carpi
sively from a distoproximal direction
radialis brevis ++ + + + +
rather than sinmltaneously, and this
Extensor carpi
pattern of flexion prevents the palmar
skin from making the necessary sur- ulnaris ++ +++
Extensor carpi
face contact with the object.
In the absence of resistance, the radialis longus + ++ +
flexor digitorum profundus is the pri-
mary finger flexor. However, when re- Figure 36 Participation of the wrist motors in wrist extension (1) when making a soft
sistance is encountered, the flexor fist and (2) when making a tight fist. +++ = maximum activity, ++ = mild activity,
digitorum superficialis becomes acti- + = minimal activity.
vated to assist in proximal interpha-
langeal flexion and the interossei
become more responsible for meta-
carpophalangeal flexion.
The opening of the fmgers is an es-
sential prerequisite for the act of pre-
hension. As in finger flexion, exten-
sion occurs through a complex
interaction of active and passive Extensor carpi ulnaris +++ + ++
forces. Extension of the metacar-
pophalangeal joint is controlled by the
Flexor carpi ulnaris +++ + + +
long extensor. Although a direct con-
nection between the extensor tendon
Extensor carpi
radialis brevis
++
and the proximal phalanx is usually Palmaris longus + +
present, action at the metacarpopha- Extensor carpi
langeal joint occurs primarily through radialis longus +
two indirect mechanisms. First, an in-
direct action is exerted in conjunction
Flexor carpi radialis +
with the flexor digitorum superficial-
is.6 With the metacarpophalangeal Figure 37 Participation of the wrist motors in wrist extension (1) when opening the fin -
and proximal interphalangeal joints in gers gently and (2) when opening the fingers forcefu lly. +++ = maximum activity,
full flexion, the initial pull of the ex- ++ = mild activity, + = minimal activity.
tensor acts on the middle phalanx via
the central slip. This force is transmit- The proximal interphalangeal joint Lateral motion and rotation of the
ted through the proximal interpha- is extended by the active force of the fingers are determined by the intrinsic
langeal joint to the head of the proxi-
lumbricals and central slip of the long muscles. The dorsal interossei abduct
mal phalanx, producing extension at
extensor. When the proximal inter- or spread the fingers, whereas the volar
the metacarpophalangeal joint. The
phalangeal joint extends actively, the interossei adduct the fingers relative to
flexor digitorum superficial is is neces-
sary in this action to prevent initial oblique retinacular is subjeded to a functional axis passing through the
proximal interphalangeal extension. tension and automatically extends the third metacarpal. There is more ab-
Second, as the metacarpophalangeal distal joint.20 This is another mecha- duction to the finger in extension and
joint extends, the sagittal bands mi- nism of coordination on the extensor less in flexion because of the relative
grate proximally, over the metacar- side of the finger. Additionally, the laxity of the collateral ligaments in ex-
pophalangeal joint, allowing the pull distal joint is extended by the terminal tension. A final passive mechanism of
of the extensor hood to act through tendon, which is formed by the long flexion -extension of the finger is
the sagittal bands on the proximal extensor lateral slip but also receives a present through a tenodesis effect:
phalanx, producing further extension contribution from the corresponding wrist extension flexes the fingers, and
at the metacarpophalangeal joint. intrinsic tendons (Figure 39). wrist flexion extends them.

A ·•\.,•
.,
c
Figure 40 Field of motion of the thumb.
The basic motions are: 1 to 2, extension
and abduction in the palmar plane; 2 to
D 3, abduction in the plane perpendicular
to the palm w ith pronation; 3 to 4, f lex-
ion, adduction, and further pronation;
4 to 1, extension and palmar abduction
with supination; 1 to 4, flexion, adduc-
tion, and pronation.
Figure 39 Extensor system for the distal
Figure 38 Landsmeer's concept of coordi· interphalangeal joint. 1 = terminal ten-
don, 2 = middle slip, 3 = lateral slip,
that occurs as the pad of the thumb is
nation of interphalangeal joint flexion.
A, Finger in extension. B, Active flexion at 4 = intrinsic tendon, 5 = quadrilatera l set against the pad of a corresponding
the distal interphalangeal joint increases lamina. finger. To bring about opposition, the
tension in the terminal extensor tendon thumb is abducted in a plane perpen-
and oblique retinacular ligament. Exten- dicular to the palm and flexed and ro-
sor trifurcation advances distally, exten- Thumb tated (pronated) on its long axis (Fig-
sor central slip relaxes, and the middle
Motion of the thumb occurs through un: 42). The thumb and the pad of
joint flexes automatically to the same de-
gree. C and D, As flexion continues, the the trapeziometacarpal, metacar- the finger make contact along the
middle slip increases in tension. Trifurca- pophalangeal, and interphalangeal equiangular spiral curve of the finger.
tion advances more distally, relaxing the joints. Flexio n-extension motion oc- This action involves motion at all
lateral tendons and terminal tendon, in-
curs in the plane parallel to the palm three articulations of the thumb, with
cluding the oblique retinacular ligament.
The distal joint then f lexes w ithout en- with flexion being across the palm, the carpometacarpal joint being the
countering extensor resistance. toward the hypothenar eminence, and most important. Overall, the
extension being away from the palm. carpometacarpal joint allows approxi-
Extension has also been referred to mately 50° to 60° of fl exion-
as radial abduction. Abduction- extension, 40° to 45° of abduction-
adduction of the thumb occurs in the adduction, and 10° to 20° of axial
plane perpendicular to the palm. rotation.22
The thumb sweeps a conoid sur- Opposition occurs in multiple
face21 through circumduction. This stages (Figure 42). First, the thumb is
curved surface is flattened on the pal- extended and supinated to open the
mar aspect (Figure 40) . All functional first web space. This is motored by the
A B
activities of the thumb occur within abductor pollicis longus, extensor
this envelope. Through flexion- pollicis brevis, and abductor pollicis
adduction, the thumb traces the seg- brevis. Additionally, the extensor pol-
ment of the base of the cone along the licis longus acts to extend (and hyper-
palmar surface. The curve traced dur- extend) the interphalangeal joint,
ing this motion is an equiangular spi- br inging the thumb tip farther from
ral21 (Figure 41) . Th rough extension- the palm. The thumb is then sequen-
abduction, the ray returns to its initial tially abducted, flexed, and pronated
Figure 41 The thumb traces an equian-
position. to position the tip against the pad of a
gular spiral when sweeping t he palmar A fundamental function of the corresponding finger. This action is
surface from A to B. thumb is opposition with the fingers determined by the abductor pollicis

Chapter 8: Kinesiology and Functional Ch aracteristics of the Upper Limb 115
brevis, opponens pollicis, and the Abduction in plane

flexor pollicis brevis. ln weak opposi- perpendicular
to plane of palm
tion, the action of the opponens pol-
licis predominates. 23 As the force of
\
1 Clomping
opposition increases, tlexor pollicis action
of thumb
brevis activity increases and exceeds
the opponens pollicis (Figure 43). In d
forceful opposition to the ulnar cligits,
the opponens pollicis becomes more
predominant and the adductor polli-
cis becomes involved. Adclitionally, as A 8
resistance increases, the extrinsic
muscles are recruited.
Figure 42 Opposition of the thumb. A, Initially, the first wet? space is opened by exten-
sion and supination of the thumb (a to b). The thumb is then abducted through curve 1
Functional Activities (b to c), bringing it perpendicular to the palm. Flexion (curve 2) and pronation (curve 3)
complete the motion, positioning the thumb tip agai nst t he tip of a corresponding fin-
The functional activities of the hand ger (c to d). B, In full opposition, the thumb tip is fully pronated, with the two nails
are extensive but can be grouped into nearly parallel and opposite one another.
nonprehensile and prehensile activi-
ties. The former includes touching,
feeling, pressing down with the fin-
gers, tapping, vibrating the cord of a
musical instrument, lifting or pushing
with the hand, etc. Prehensile activi-
ties are grouped into precision and
power grips. 23 Precision grip involves
participation of the radial side of the
hand with the thumb, index, and
middle fingers to form a three-jaw
chuck. When the pads of these digits 0 + FB + + +
come into contact, the grip is de- APB + + 0 + +
FB + APB +
scribed as palmar, whereas fo r very
precise work, contact with the tip of
the same digits creates a tip type of
grip. A lateral, or key, grip involves A B
contact of the pad of the thumb with
the lateral aspect of the correspond- Figure 43 Muscle activity during A, weak opposition, and B, strong opposition. 0 = op-
ponens pollicis; APB = abductor pollicis brevis; FB = flexor pollicis brevis. +++=maximum
ing finger in its distal segment.
activity, ++ = mild activity, + = minimum activity.
A power grip predominantly in-
volves the ulnar aspect of the hand
with involvement of the little and ring by the thenar eminence. More power its contribution with the thenar mus-
fingers. The radial three digits also is provided to this grip when the cles and the flexor pollicis longus.
participate actively either in a pure thumb wraps around the flexed fm- The spherical grip is used to hold
power pattern form or by adding an gers. If an element of precision is nec- objects such as a ball. It is similar to a
element of precision to the power essary, the thumb will adopt a longi- cylindrical grip in terms of motor
grip. The power grip can be divided tudinal position of adduction that force, although the interossei are
into three subtypes: cylindrical, allows for small adjustments of pos- more active as a result of the abduc-
spherical, and hook. Despite the many ture. In general, the pattern of the tion of the metacarpophalangeal
functions of the hand, any prehensile grip during prehension inletermined joints. When a large object is held, a
act, when arrested instantaneously, by the intention and not necessarily power grip is used with minimal flex-
might fit in one of these patterns in a by the shape of the object. 24 Finger ion of the fingers, which are abducted
pure or combined form. flexion is primarily powered by the and rotated, and the thumb partici-
In a cylindrical grip, all fingers are flexor digitorum profundus. The pates at the opposite pole by stabiliz-
flexed maximally, such as around the flexor digitorum superficialis and the ing the object and providing the
handle of a tool, and the counterpres- interossei become involved if more necessary counterpressure. With a
sure to the flexing fingers is provided power is necessary. The thumb brings smaller spherical object, the fingers

are adducted and th e thumb is in op- 6. Simon SR, Alaranta H, An KN, et al: 15. Halls AA, Travill A: Transmission of
position; this pattern of prehension is Kinesiology, in Buckwalter JA, Ein- pressures across the elbow joint. Anat
horn TA, Simon SR (eds): Orthopaedic Rec 1964;150:243-247.
of the precision type.
Basic Science: Biology and Biomechanics 16. MacCo naill MA, Basmajian JV (eds):
The hook power grip involves flex-
of the Musculoskeletal System, ed 2. Muscles and Movements: A Basis for
ion of both interphalangeal joints, es- Rosemont, IL, American Academy of Human Kinesiology. Baltimore, MD,
pecially the proximal interphalangeal Orthopaedic Surgeons, 2000, pp 731- Williams &Wilkins, 1969.
joint, and minimal participation of 827. 17. Sarrafian SK, Melamed JL, Goshgarian
the metacarpophalangeal joint. The 7. Morrey BF, Chao EY: Passive motion GM: Study of wrist motion in flexion
flexor digitorum profundus and of the elbow joint. J Bone Joint Surg Am and extension. Clin Orthop 1977;126:
flexor digitorum superficialis are both 1976;58:501 -508. [53-159.
involved. This pattern is used in car- 8. Long C II, Conrad PW, Hall EA, Furler 18. Radonjic D, Long C II: Kinesiology of
rying a suitcase and can be main- SL: Intrinsic-extrinsic muscle control the wrist. Am J Phys Med 1971 ;50:
of the hand in power grip and preci- 57-71.
tained for a prolonged period of time.
sion handling: An electromyographic 19. Littler JW: On the adaptability of
study. J Bone Joint Surg Am 1970;52: man's hand: With reference to the
References 853-867. equiangular curve. Hand 1973;5:187-
9. Funk DA, An KN, Morrey BF, Daube 19L.
L. Morrey BF, Itoi E, An KN: Biomechan-
JR: Electromyographic analysis of 20. Landsmeer JMF: The anatomy of the
ics of the shoulder, in Rockwood CA
muscles across the elbow joint. dorsal aponeurosis of the human fin-
Jr, Matsen FA III, Wirth MA, Harry-
J Orthop Res 1987;5:529-538. ger and its functional significance.
man DT (eds): The Shoulder, ed 2.
Philadelphia, PA, WB Saunders, 1998, 10. Travill AA: Electromyographic study AnatRec 1949;104:31-44.
pp 233-276.
of the extensor apparatus of the fore- 21. Littler JW: Hand structure and func-
arm. Anat Rec 1962;144:373-376. tion, in Littler JW, Cramer LM, Smith
2. Inman VT, Saunders JR, Abbott LC:
l L. Capener N: The hand in surgery. JW (eds): Symposium on Reconstructive
Observations on the function of the
J Bone Joint Surg Br 1956;38: 128-151. Hand Surgery. St Louis, MO, CV
shoulder joint. J Bone Joint Surg 1944; Mosby, 1974, pp 3-12.
12. Hollister AM, Gellman H, Waters RL:
26: 1-30.
The relationship of the interosseous 22. Cooney WP III, Lucca MJ, Chao EY,
3. Howell SM, Imobersteg AM, Seger Linscheid RL: The kinesiology of the
membrane to the axis of rotation of
DH, Marone PJ: Clarification of the thumb trapeziometacarpal joint.
the forearm. Clin Orthop 1994;298:
role of the supraspinatus muscle in 272-276. J Bone Joint Surg Am 198 l;63: 1371-
sho ulder function. J Bone Joint Surg 1381.
13. O'Driscoll SW, Horii E, Ness R, Ca-
Am 1986;68:398-404. halan TD, Richards RR, An KN: The 23. Forrest WJ, Basmajian JV: Functions
4. American Academy of Orthopaedic relationship b etween wrist position, of human thenar and hypothenar
Su_rgeo ns: Joint Motion: Method of grasp size, and grip strength. J Hand muscles: An electromyographic study
Measuring and Recording. Chicago, IL, Surg Am 1992;17:169-177. of twenty-five hands. J Bone Joint Surg
American Academy of Orthopaedic 14. Christensen JB, Adams JP, Cho KO,
Am 1965;47:1585-1594.
Surgeons, 1965. Miller L: A study of the interosseous 24. Napier JR: The prehensile movements
5. Boone DC,Azen SP: Normal range of distance between the radius and ulna of the human hand. J Bone Joint Surg
motion of joints in male subjects. during rotation of the forearm. Anat Br 1956;38:902-913.
J Bone Joint Surg Am 1979;61:756-759. Rec 1968; 160:261-271.

Body-Powered Components
Gerald E. Stark Jr, CP
Introduction
Body-powered components have been motion or force because of the lim- and develop bimanual skills. Passive
used in upper limb prostheses for ited leverage of short bony remnants. mitts are also used in sport activities,
centuries and are still commonly pre- Finally, the robot-like appearance of especially where physical contact with
scribed today. Body-powered control some. body-powered components can more rigid terminal devices could
indicates that an upper limb prosthe- be disconcerting to the genera.I public cause injury to the wearer or other
sis uses body movements, harnessed as well as to the amputee. participants. Some passive devices
with control straps and cables, to op- have specialized shapes to facilitate
erate the various prosthetic compo- particular recreational activities.
nents or controls.
Terminal Devices Passive terminal devices that func-
When body power is insufficient or The most distal component of an up- tion primarily as specialized tools are
undesirable, externally powered com- per limb prosthesis is called the ter- also available. Some are shaped for
ponents may be used. External power minal device. Terminal devices can be specific tasks whereas others have
is derived from a source outside the classified as passive or active prehen- adapters that allow direct attachment
body. Although contemporary ver- sile devices. Because passive devices of various standard tools to the pros-
sions are battery-powered electronic do not require moving parts, cables, thetic wrist (Figure 3) . These terminal
devices, pneumatic, hydraulic, and or batteries for operation, they are devices provide a wide array of tool
other power sources have been used typically light in weight and reliable. options for carpentry, gardening, do-
in the past. mestic chores, and mechanic work.
Body-powered cable systems, de- Passive Terminal Devices Virtually any tool can be adapted by
veloped from common bicycle con- The most common.ly prescribed pas- the custom addition of an attachment
trols, offer the advantages of low cost, sive terminal device is the passive with a spring-operated ball. The tool
light weight, and high reliability be- hand (Figure 1). Many passive hands can then be quickly inserted into the
cause of their mechanical simplicity. have bendable or spring-loaded fin- device and positioned in pronation or
Their widespread use throughout the gers that can provide a static grasp for supination in 90° increments. Some
world underscores the practical ad- objects. The more natural appearance partial hand amputees use a soft
vantages of these components. of the terminal device provides in- wrist-hand orthosis to attach such
Body-powered control systems also creased social acceptance. Partial tools to the palmar area for intermit-
have significant disadvantages. The hand or finger prostheses can provide tent use.
harness required to transmit muscle opposition for remaining fingers or a
forces inevitably restricts the ampu- mobile thumb. Active Prehensile Devices
tee's work envelope and encumbers Some passive terminal devices re- Prehensors offering active grasp may
the unaffected side. The amputee semble children's mitte·ns and hence be classified according to their mode
must often exert significant effort and they are called "mitts" (Figure 2). The of operation. Voluntary-opening de-
grossly exaggerate body movements passive mitt has a soft and flexible vices are normally held closed by a
to generate sufficient force and excur- shape similar to the cupped human spring or rubber band mechanism
sion to operate the component. hand. Mitts are often recommended and opened when the control cable is
Higher-level amputees may be physi- as the first terminal device for infants pulled. The object is then grasped
cally unable to generate sufficient as they learn to sit up, crawl, walk, with the pinch force proportional to

Figure 1 Passive hands w ith

bendable fingers are valued
for their cosmetic appeal,
light weight, and basic func-
tion. A stock production or
custom cosmetic glove is
pulled over the hand to pro-
vide the outer covering. Figure 2 Flexible passive mitts are available in a variety of designs, sizes, and skin tones. A. Infant
(Courtesy of Hosmer mitt. B, Closed crawling mitt. C, Child mitt. D, Sport mitt. E, Flexibility and skin tone options.
Dorrance Corp, Campbell, F, Passive catching terminal device. G, Passive "mushroom" gymnastic terminal device. {A and B
CA) Courtesy of Hosmer Dorrance Corp, Campbell, CA. C through G courtesy of Therapeutic Recreation
Systems, Boulder, CO)
~
A
By B
Figure 5 Specialized work hook- type
terminal device. A, Model 7 farmer's
hook. B, Model 6 farmer's hook with
back-lock featu re. (Courtesy of Hosmer
Dorrance Corp, Campbell, CA)
Figure 3 A, N-Abler II terminal device

wit h adjustable f lexion wrist for use
with task-specific interchangeable tools.
B, Small sample of interchangeable
hand t ools. (Courtesy of Texas Assistive c D
Devices, LLC, Brazoria, TX)
Figure 4 Voluntary-opening hook-type
terminal device. A, Model SX adult ter-
minal device. B, Model 88X small adult
terminal device. C, Model 10 children's
terminal device. D, Model 12P infant's
terminal device. (Courtesy of Hosmer

Chapter 9: Body-Powered Components 119
the number of rubber bands or satisfactory for all but the most rug- engage either one spring ( 1.6 kg) or
springs used when cable tension is re- ged of users. Originally all hooks were two springs (3.2 kg) to vary the pinch
leased. The object can then be held stainless steel, but this material is now force. Because the fingers are hollow
passively until the user applies force usually reserved for heavy-duty users alloy, they are not suit~ble for heavy-
to the control cable to release the ob- with more rugged demands, particu- duty use. The 555 book is an alunu-
ject. Inversely, voluntary-closing de- larly those with transradial amputa- num alloy hook with more rugged
vices are normally held open and tions. For transhumeral and higher solid fingers in the same lyre shape;
close when the control cable is pulled. levels of loss, aluminum alloy hooks the 555-SS model offers the same de-
Pinch is regulated by the amount of are generally preferred because of the sign in stainless steel (Figure 7).
force the user applies to the control ease of elbow flexion facilitated by the Because most amputees find the
cable. Prehensors may also be subdi- reduced terminal weight compared canted approach satisfactory, the lyre
vided into hand-like and utilitarian with steel devices. The series 8 hooks shape is more commonly prescribed
shapes. The traditional utilitarian are slightly smaller and intended for for use by bilateral upper limb ampu-
shape is the split hook. women or teens; the series 10 is for tees on the nondominant side to pro-
children, and the series 12 is an in- vide an alternative prehension pattern
Voluntary-Opening Hooks fant's hook. Addition of the letter P that is optimized for cylindrical ob-
Many voluntary-opening hook termi- indicates that the hook has been jects. The combination of a canted
nal devices are fairly similar in func- coated with plastisol, a soft rubber hook with a lyre-shaped hook offers
tion and shape and differ primarily in material available in a variety of skin individuals with bilateral upper Jimb
size and material. The original split- tones. This soft coating provides a loss ready access to different gripping
hook design was created in 1912 by moderate amount of protection for geometries.
D.J. Dorrance, an upper limb ampu- the user and siblings. The CAPP terminal device, origi-
tee, to provide active prehension (the A second characteristic shape is the nally developed at the Child Amputee
traditional C-shaped hook used in the work hook, identified by the number Prosthetics Project at UCLA, offers
days of pirates was a passive device). 7. This device has a large opening be- voluntary opening function with a
Because of its versatility and reliabil- tween the two fingers that is designed unique shape that is neither book nor
ity, the voluntary-opening hook with to grasp shovel handles and similar hand like (Figure 8) . Clever use of
canted fingers is the most commonly objects (Figure 5, A). This heavy-duty contours and rubber materials pro-
prescribed terminal device in North stainless steel device is commonly vides a reasonably secure grasp de-
America (Figure 4). European manu- prescribed for adult male amputees spite the limited pinch force that a
facturers also offer voluntary-opening who perform manual labor. The spe- child can generate. Children fre-
hooks, and many offer alternative cialized fingers also have a number of quently refer to this device as their
grip-force springs and finger geome- subtle contours that facilitate holding, "alligator" or "helper." This ternunal
tries that differ from the more famil- grasping, and carrying such items as device is popular for children because
; ar American designs. buckets, chisels, knives, nails, and car- initially the caregiver can place ob-
A numbering system developed by pentry tools. Although sometimes rejects in its grip, but the device does
the major American producer of ferred to as a "farmer's hook," the de- not require much body-powered force
hooks is commonly used to identify vice has value for anyone engaged in for the child to open it to release the
the type of hook being prescribed. manual tasks, including workshop ac- object. The shape is neutral, for left or
Each number and letter denotes the tivities. Another variation, termed right side use, and can be cabled by
size, shape, or type of hook. The "LO," has a larger opening between the prosthetist to offer either an exter-
series 5 hooks are the standard adult the finger tines to better grasp large- nal or internal exit for the cable pull.
size with canted fingers. The term diameter handles and brooms. The
"canted" refers to the slanted configu- series 6 has the same finger shape as Voluntary-Closing Hooks
ration of the hook fingertips, which the 7 but includes a back-lock feature Voluntary-closing hooks normally
facilitates visual feedback during fine that prevents the hook from opening open when the amputee is relaxed, are
motor tasks. Because no prehensor inadvertently when lifting a heavy closed by pulling the control cable, re-
yet offers sensa.tion, the amputee load (Figure 5, B. sulting in a direct gradient of pinch
must rely on vision to confirm that Some hook fingers offer a symmet- force, depending on the force applied.
grasp has been successful. The letter X ric shape that faci litates grasp of cy- The pinch force at the fingers can be
indicates the addition of nitrile rub- lindrical objects such as bottles more very light or extremely strong because
ber finger linings to improve friction easily than canted fingers (Figure 6). it is not limited by the number of
and grasp, especially on metal objects The "two-load" hook has lyre-shaped rubber bands or springs, as is the case
like doorknobs. The letter A indicates fingers for this purpose. As the name with voluntary-opening devices. Most
aluminum aUoy, which reduces the suggests, a small switch at the base of voluntary-closing hooks do not have
weight of a steel hook by 50% and is the thumb permits the amputee to an inherent locking mechanism, so

120 Section II: Th e Upper Limb
Figure 6 Two-load Figure 7 Model Figure 8 The CAPP

hook. (Courtesy of 555-SS, lyre- terminal device,
Hosmer Dorrance shaped hook in referred to by chil-
Corp, Campbell, stainless steel. dren as their "alliga-
CA) (Courtesy of tor" or "helper," pro-
Hosmer Dorrance vides a unique set of
Corp, Campbell, gripping surfaces.
CA) (Courtesy of Hosmer
Dorrance Corp,
Campbell, CA)
Figure 9 A, The TRS Grip voluntary- Figure 10 APRL vol-

closing terminal device has multiple untary-closing hook.
gripping geometries and is available in (Courtesy of Hosmer
steel, aluminum alloy, or titanium. Dorrance Corp,
B, Plastic coating is also available. Campbell, CA)
(Courtesy of Therapeutic Recreation
Systems, Boulder, CO)
Figure 11 APRL volun- Figure 12 Soft volun- Figure 13 Becker Lock- Figure 14 Sierra volun- Figure 15 Dorrance
tary-closing hand. _tary-closing hand. Grip hand. (Courtesy of tary-opening hand. voluntary-opening
(Courtesy of Hosmer (Courtesy of Hosmer Hosmer Dorrance Corp, (Courtesy of Hosmer hand. (Courtesy of
Dorrance Corp, Dorrance Corp, Campbell, CA) Dorrance Corp, Hosmer Dorrance Corp,
Campbell, CA) Campbell, CA) Campbell, CA) Campbell, CA)
the amputee must apply continuous voluntary-closing terminal devices dren in aluminum, steel, and tita-
force on the cable to maintain the may be used for transhumeral and nium, with and without urethane
grasp on an object. Although this is higher levels of amputation, the har- coatings. These terminal devices fea-
physiologically normal, some patients ness design requires special attention tme multiple cylindrical gripping sur-
find this requirement objectionable to conserve cable excursion. faces within the fingers for gross mo-
and prefer other terminal devices. The most popular group of tor prehension; fine prehension is
Acceptance of voluntary-closing voluntary-closing devices is the TRS provided by the fingertips. To main-
terminal devices has been greatest fo r Grip and Adept series (Therapeutic tain grasp, a ball cleat assembly can be
children and unilateral transradial Recreational Systems, Boulder, CO) attached to the forearm that engages a
amputees, particularly those with (Figure 9). These unique terminal de- ball on the cable; alternatively, the ter-
long residual limbs. Although vices are available for adults and chil- minal device can be modified so that

a pin inserted proximally keeps the simplifying ilie internal mechanisms. can be opened from ilie fully closed
thumb in the closed position. Client Originally developed for pediatric position only when tension is applied
acceptance has been particularly use, these designs employ a soft poly- to the control cable by the amputee.
strong among children and athletic mer hand-like exterior with the Lock-Grip hands are available in mul-
adults because the uncoated versions thumb and first two fingers providing tiple sizes. The Imperial model, avail-
are very rugged and durable. three-jaw chuck-grip prehension. able in a large adult size only, permits
The APRL hook was developed by These hands come in a variety of easy adjustment of finger prehension
the Army Prosthetics Research Labo- adult, child, and infant sizes. The force with a screwdriver.
ratory after World War II using biceps APRL hand (Figure 11), available only Sierra Voluntary-Opening Hand
cineplasty as the source for body in an adult male size, has features The Sierra voluntary-opening hand
power (Figme 10). This voluntary- similar to the APRL hook- an auto- (Hosmer Dorrance, Campbell, CA),
opening device has replaceable lyre- matic back-lock feature for holding like tlhe APRL hand, has a two-
shaped hook fingers with a mecha- objects and two grip openings. position stationary thumb (Figure
nism that allows two different finger Body-powered hands are also 14). From the fully closed position,
openings and a gripping back-lock available with the same finger assem- control cable tension causes the first
feature enabling the user to passively blies and external appearance (when two fingers to move away from the
hold an object. The back-lock feature ilie cosmetic glove is applied) as elec- thumb. As tension on the control ca-
can be turned off for a "freewheeling» tronic hands (Figure 12). These hands ble is relaxed, springs cause the fin-
mode. The device is unique among are also available in a voluntary- gers to move back toward the thumb.
hooks in that the operating lever or opening configuration. A back-lock feature operates in all
thwnb is located on the ulnar side of finger positions, enabling the ampu-
the device. Like other voluntary- Voluntary-Opening Hands tee to hold heavy objects securely.
closing terminal devices, the APRL Although a nwnber of voluntary- Finger opening and release of the
hook provides graded prehension, ie, opening hands are available, few are back-lock mechanism are operated
the pinch force is as gentle or strong used as active terminal devices. In ad- simultaneously through a single con-
as the force generated by the amputee. dition to the problems of frictional trol cable. The Sierra voluntary-
This capability is believed to improve loss, restricted motion by the glove, opening hand is available in a large
proprioception, particularly with and contours that block visual inspec- adult size only.
cineplasty actuation. Unfortunately, tion, all voluntary-opening devices Dorrance Functional Hands
the mechanical complexity of this de- offer only linuted pinch force. These Dorrance voluntary-opening hands
vice renders it both costly to manu- factors significantly limit their useful- (Hosmer Dorrance, Campbell, CA)
facture and prone to breakdown. Al- ness for grasp and release tasks. allow the prosthetist to adjust finger
though the graded prehension is of Many amputees want an inter- prehension by installing different ten-
particular value to selected bilateral changeable hand for social occasions sion springs (Figure 15). They are
upper limb amputees, the hollow alu- in addition to a utility hook device available in a range of adult sizes.
minum lyre-shaped fingers it shares for general use; this is the most com- Soft Voluntary-Opening Hand
with the two-load hook are somewhat mon indication for prescribing a Soft voluntary-opening hands have
fragile. Given the small remaining body-powered hand. Voluntary- internal aluminum or nylon frames
population of amputees with cine- opening hands are rarely appropriate covered by a soft plastic shell. Some
plasties, the APRL hook is currently for bilateral upper limb amputees be- also have an adjustable pinch force
prescribed primarily for satisfied pre- cause of their grip limitations. Exter- from 1 to 6 lbs wiili a back-lock
vious wearers. nally powered hands offer far greater mechanism when the hand is closed.
pinch force and much better grasp They are offered with a dorsal or pal-
Voluntary-Closing Hands and release function and are conse- mar cable exit in a range of adult sizes
Although voluntary-closing hands quently often preferred over body- (Figure 16).
theoretically offer the san1e advantage powered hands. CAPP Voluntary-Opening Hand
of graded prehension as hooks, the Lock-Grip and Imperial Hands This voluntary-opening hand for chil-
frictional losses in the mechanism are The Lock-Grip (Figure 13) and Impe- dren uses the same "alligator" mecha-
much greater. The rubber-like cos- rial hands (Becker Mecha11ical Hand nism found in ilie CAPP terminal
metic glove that covers the hand fur- Corp, St. Paul, MN) are voluntary- device in a gloveless urethane config-
ther impedes motion, and the thick opening hands with control cable ten- uration that resembles a hand (Hos-
fingers often block visual feedback sion that causes all five fingers to mer Dorrance, Campbell, CA) (Figure
from the fingertips. Functional open in spherical and cylindrical pre- 17). This creates an easy-to-operate
voluntary-closing hands are now hension. The Lock-Grip model con- voluntary-opening device that looks
available that reduce the frictional tains a mechanism that locks the fin- more natural than either the CAPP
losses by eliminating ilie glove and gers in the closed position. Fingers terminal device or a hook.

122 Section U: The Upper Limb
Figure 16 A, Soft voluntary-opening hand. (Courtesy of Hosmer Dorrance Corp, Figure 17 CAPP voluntary-opening
Campbell, CA) B, Components of soft voluntary-opening hand- inner mechanism, inner hand. (Courtesy of Hosmer Dorrance
hand shell, and outer cosmetic glove. (Courtesy of Otto Bock Healthcare-USA, Corp, Campbell, CA)
Minneapolis, MN)
Figure 18 Custom Figure 19 Custom- tions are usually made of a special sil-
production glove. sculpted glove. icone elastomer that is more stain re-
(Courtesy of (Courtesy of sistant than the polyvinyl chloride
Hosmer Dorrance Aesthetic Concern,
plastic commonly used in the less ex-
Corp, Campbell, Middletown, NY)
CA)
pensive gloves. Some prosthetists re-
fer the amputee directly to a cosmetic
restorationist, who creates a custom-
sculpted glove that precisely matches
the amputee's appearance and fits
perfectly over the completed prosthe-
sis (Figure 19). Custom-sculpted
gloves can be fashioned to fit over
_both passive and active prosthetic
hands, including myoelectrically 'con-
trolled devices.
like appearance of a stock glove can

Wrist Units
Cosmetic Gloves
be improved by subtle painting of Prosthetic wrist units attach the ter-
The cosmetic glove is a rubberized
veins and other structural details, or minal device to the prosthesis and
covering that protects the hand mech-
the application of fingernail polish. provide active or passive pronation
anism from contamination and also
A custom production glove is and supination of tl1e terminal device.
modifies the external appearance of
manufactured from a donor mold of With most body-powered systems, the
the prosthesis. The glove is applied terminal device is simply screwed into
a hand similar in shape to the ampu-
over the shell of a passive hand or the wrist, which is permanently an-
tee's. The prosthetist sends a precise
over the mechanism of an active pre- mold of the partial hand amputation chored into the forearm section.
hensor and must be replaced at regu- to the factory so that the best match The amputee must be provided
lar intervals when it deteriorates from can be selected. A wider selection of with a full range of pronation and su-
the wear and tear of normal use. skin tones is available than for the pination so tl1at tl1e terminal device
Three different levels of cosmetic stock glove, and realism can be en- can be positioned in the most func-
appearan ce can be provided. A stock hanced by artistic painting and fin- tional attitude for specific tasks. The
production glove, the least costly and gernail polish (Figure 18). degree of volu ntary pronation and
most commonly prescribed covering, The custom-sculpted glove offers supination retained depends prima-
is ordered by !he prosthetist on the the most natural appearance. The rily on the length of the remaining ra-
basis of approximate hand size and glove is handmade from a sculptured dius and ulna. When more than half
skin tone. Most come in generic male, reverse copy of the remaining hand. the forearm bones have been lost to
female, adolescent, and child contours The skin tones and color are matched ampu!l!ti.on, little or no voluntary pro-
in roughly two dozen shades of pink using a calibrated photograph of the nation and supination can be cap-
to brown skin tones. The mannequin- unaffected side. These artistic restora- t ured by the socket. Even at the very

\
f ',,'
B A
Figure 21 Low-profile friction wrist for

~
c wrist disarticulation prostheses.
(Courtesy of Hosmer Dorrance Corp,
l
Campbell, CA)
Figure 20 A, "Economy" friction wrist Figure 23 A, Inner friction unit for con-
model. B, Inner rubber washer provides stant-friction wrist with nylon ring.
friction. C, Heavy-duty version with steel 8, Mechanical-type constant-friction
or titanium straps. (Courtesy of Hosmer Figure 22 Oval-shaped friction wrist wrist. (Courtesy of Hosmer Dorrance
Dorrance Corp, Campbell, CA) unit. (Courtesy of Hosmer Dorrance Corp, Campbell, CA)
Corp, Campbell, CA)
D E F
Figure 24 A, Large, round constant-friction wrist. 8, Oval shape. C, Medium size, round shape. D, Infant size.
E, Lightweight and simple Delrin wrist. F, Simple collar-type friction for Delrin Wrist. (Courtesy of Hosmer
long transradial levels of amputation, device into the desired position. Fric- cause the hand and wrist contours are
pronation and supination can be re- tion wrist units are available in alumi- no longer congruent.
stricted by some self-suspending num or stainless steel and in a full Friction wrist units are durable
supracondylar socket designs that ef- range of infant, child, and adult sizes. and economical but do not provide a
fectively block all pronation and supi- Special friction wrist units designed constant resistance to pronation and
nation by extending proximally above for wrist disarticulation prostheses are supination. With these older designs,
the elbow joint. made as th in as possible to minimize a rubber washer is compressed to cre-
the length of the prosthetic forea rm ate friction as the terminal device
Friction Wrist Units beyond the residual limb (Figure 21) . stud is screwed into the wrist unit. As
Friction wrist units are the most com- Oval-shaped friction wrist units are the ter minal device is unscrewed, fric-
monly prescribed wrist option. A set available in adult and medium sizes tion is reduced; consequently, the sta-
screw or spacer washers are adjusted and provide a smoother transition to
bilizing force varies with the prona-
so that sufficient friction is applied to the socket contours for long transra-
tion or supination position of the
prevent terminal device rotation un- dial levels of amputation (Figure 22) .
terminal device.
der load, yet not so much that the am- Because many prosthetic hands have
putee cannot manually rotate the ter- an oval base, the oval-shaped wrist Constant-Friction Wrist
minal device with the sound hand unit also provides a smoother transi-
tion from the prosthetic hand to the
Units
(Figure 20). Bilateral amputees usually
preposition their terminal devices by prosthetic forearm. When the pros- Constant-friction wrist units are gen-
striking one against the other, or by thetic hand is rotated into pronation erally preferred because they are de-
gripping a stable object such as a table or supination, however, there will be a signed to provide constant friction
edge and then rotating the terminal noticeable prominence at the wrist be- throughout the range of rotation of

Figure 26 Ring-type quick-change Figure 27 Flexion wrist. A, Adult version.

wrist unit. (Courtesy of Hosmer B, Smaller medium size. (Courtesy of
Dorrance Corp, Campbell, CA) Hosmer Dorrance Corp, Campbell, CA)
Most quick-disconnect units em- with prostheses. Because the mecha-

ploy an adapter, which is screwed nism adds weight near the termina-
tightly on the threaded stud of the tion of die prosthesis, it is sometimes
Figure 25 A, Quick-change wrist.
various terminal devices to be inter- prescribed only for the dominant
Disconnect mechanism with insert nut (far
right). B, Pushbutton-type. C, Medium size. changed. In these units, light down- side. Two types of mechanism can
(Courtesy of Hosmer Dorrance Corp, ward pressure on the activating lever provide wrist flexion.
Campbell, CA) by the amputee unlocks the terminal The flexion wrist replaces the com-
device but does not cause its ejection. mon constant-friction wrist and al-
With the terminal device unlocked, lows manual prepositioning of the
the terminal device. Most constant- the amputee manually rotates the de- terminal device in neutral, 30° of
friction units employ a nylon- vice to the desired attitude of prona- volar flexion, or 50° of volar flexion
threaded insert (Figure 23). When a tion or supination. Application of a (Figure 27). The terminal device can
small set-screw in the body of the proxinlally directed axial force with also rotate about its mounting stud in
wrist is tmned, the nylon thread is the sound hand will then lock the ter- any of the positions.
deformed against the stud of the terminal device in the new position. The wrist flexion unit is used in
minal device, creating constant fric- Heavy downward pressme on the ac- conjunction with the friction wrist
tion. When the threads wear out, the tivating lever causes ejection of the (Figme 28). This dome-shaped device
insert can be replaced, returning the adapter and attached terminal device. also has three locking positions-0°,
wrist to like-new condition. Some This option is popular when using the 25°, and 50° of volar flexion. Because
versions use a mechanical wedge that device through a cosmetic glove. An- the entire unit can rotate where it
presses on the terminal device stud. other control option uses a ring that mounts to the wrist, the terminal de-
This design resists wear and thermal is rotated in one direction for prona- vice covers a wider work envelope
breakdown better than the nylon tion and supination positioning and than the flexion wrist. This can be ad-
in the other direction for disconnec- vantageous for the bilateral amputee
wrists, yet has equally smooth friction
tion (Figure 26). Quick-disconnect struggling to perform midline activi-
resistance. Constant-friction wrist
units are available in an adult or me- ties. However, this unit is significantly
units are available in both row1d and
dium size witli a round or oval con- heavier and longer than the flexion
oval configurations (Figure 24). In the
figmation in either aluminum or wrist because it must be coupled in
round configuration, infant through
steel. addition to a wrist.
adult sizes are available. In the oval
Anotlier wrist option offers passive
configuration, only adult and me- Wrist Flexion Units wrist extension for pediatric use when
di um sizes are manufactured. the prosthesis is used for crawling.
Wrist flexion is particularly useful for
Quick-Disconnect Wrist activities at the midline-toileting, This wrist uses a wedge of soft foam
eating, shaving, dressing, etc. Such ac- that can compress when the passive
Units tivities are generally performed more mitt terminal device is extended. Pas-
Quick-disconnect wrist units are de- easily with the sound hand than with sive wrist extension also facilitates
signed to facilitate rapid interchange a prosthesis. For this reason, pros- such activities as holding the handle-
of different terminal devices (Figure thetic wrist flexion is seldom neces- bars of a bicycle.
25). All commercially available quick- sary for unilateral amputees unless
disconnect wrist units allow the am- range of motion is restricted in the Rotational Wrists
putee to exchange different terminal more proximal joints. However, wrist Friction wrist units described earlier
devices and to lock them down in the flexion capability is very important iu this chapter may present difficul-
desired attitude of supination or pro- for the bilateral upper limb amputee ties for amputees who engage in work
nation. who must perform all daily activities or avocational activities that exert

A
Figure 29 Rotational wrist
Figure 28 Wrist flexion unit, A, Adult size. unit. (Courtesy of Hosmer
B, Child size. (Courtesy of Hosmer Dorrance Corp, Dorrance Corp, Campbell,
Campbell, CA) CA)
Figure 30 Four-function wrist allowing
flexion, extension, pronation, and
supination. (Courtesy of Texas Assistive
Devices, LLC, Brazoria, TX)
high rotational loads on the terminal chased as an off-the-shelf device (Fig-
device. Friction and constant-friction ure 30).
wrist units tend to permit unwanted They are typically available in adult,
rotation when subjected to very high
Elbow Units medium, and child sizes.
torsional loading.
Rotational wrist units are cable- Elbow Units for Transradial Single-Axis Hinges
controlled, positive-locking mecha- Amputees Single-axis bjnges are designed to
nisms (Figure 29). In the unlocked Flexible Hinges provide axial (rotational) stability be-
mode, these units permit manual With amputation through the distal tween the prosthetic socket and resid-
prepositioning of the terminal device third of the forearm, the amputee re- ual fo1·earm during active prosthesis
in almost any attitude of supination tains a limited amount of active supi- use (Figure 32). Correctly aligned
or pronation throughout a 360° nation and pronation. Flexible hinges single-axis hinges should not restrict
range. Once locked in position, these permit active use of residual forearm the normal flexion -extension range of
units provide much greater resistance rotation, minimizing the requirement motion of tl1e ruiatomic elbow joint.
to rotation than friction units do. for manual prepositioning of the ter- The joints should be set in a certain
The bilateral amputee may find minal device by the amputee. Al- amount of preflexion to load the
that rotational wrist units better facil- though flexible hinges of metal cable stops of the joint when canying heavy
itate prepositioning of the terminal or leather are commercially available, dbjects. This helps unweight the
devices. With the wrist unit unlocked custom-made hinges of Dacron web- shorter residual limb and prevents
and the terminal devices fully supi- bing are most commonly used. They hyperextension.
nated or pronated, tension on the ter- attach proximally to the triceps pad
minal device control cable causes the and distally to the prosthetic fore- Polycentric Hinges
terminal device to rotate back to the arm and should allow prosthesis ro- Short transradial levels of amputation
neutral position. tation of at least 50% that of the an- require that the anteroproximal trim
Another wrist variation, called the atomic residual forearm rotation line of the prosthetic socket be close
four-function wrist, combines the ro- (Figure 31). to the elbow joint. With a high ante-
tational wrist with a flexion wrist. The rior socket wall, complete elbow flex-
name refers to the four wrist func- Rigid Hinges ion tends to be restricted by the
tions of flexion, extension, pronation, Amputations at or above the midfore- bunching of soft tissue in the antecu-
and supination. A rotational wrist is arm level basically eliminate the pos- bital region. Polycentric hinges reduce
spring loaded to move into a pro- sibility of transmitting active supina- this tendency for bunching by provid-
nated position when unlocked. With a tion or pronation to the terminal ing more room in the cubital area as
pull of the control cable, it is brought device. At these levels of amputation, the elbow is flexed, thereby increasing
into proper position and Jocked with the amputee must resort to manual the range of motion at this joint (Fig-
a reciprocating mechanism. A rubber prepositioning of the terminal device; ure 33 ).
band attached to the wrist brings the consequently, the use of rigid hinges
wrist into flexion when unlocked and does not restrict voluntary pronation Step-Up Hinges
is positioned in the same manner. or supination. The primary advantage Amputations immediately distal to
This type of wrist can be adapted of rigid hinges is that they protect the the elbow joint require a prosthetic
from existing componentry or pur- residual limb against torque loads. socket with extremely high trim Jines

to provide adequate stabilfry. Conse-

quently, flexion of the anatomic el-
bow joint is often restricted to 90° o r
less. In situations in which full range
of elbow flex:ion has been compro-
mised as a result of trauma or disease,
step-up hinges may be used to en-
hance remaining flex:ion to ensure
greater overall function.
A The use of step-up hinges requires
that the prosthetic forea r m and socket
Figure 31 A. Cable-type flexible hinges. B, Transradial prosthesis with Dacron f lexible be separated (Figure 34). Thus, pros-
hinges. (Courtesy of Hosmer Dorrance Corp, Campbell, CA) theses using step-up hinges are fre-
quently referred to as split-socket
prostheses. Step-up hinges amplify
the excursion of anatomic elbow joint
m otion by a ratio of approximately
2:1; thus, 60° of flexion of the ana-
tomic elbow joint causes the pros-
thetic forearm (and terminal device)
to move through a range of approxi-
mately 120° of motion. The increased
range of motion requires that the am-
putee exert twice as much force to flex
A the step-up hinge.
Figure 32 A.Three sizes of single-axis hinges. B, Transradial prosthesis with single-axis There are two types of step-up
hinges. (Courtesy of Hosmer Dorrance Corp, Campbell, CA) hinges, sliding action and geared
joints. The sliding action step-up
hinges sometimes tear clothing and
require a split-housing cable system.
Geared step-up hinges are more fully
enclosed and may use a standard
Bowden cable system. Both versions
require special fixtures to align prop-
erly.
Residual limb- Activated

locking Hinge
A : Amputees with very high transradial
levels of amputation are often unable
Figure 33 A, Polycentric hinges. B,Transradial prosthesis with polycentric hinges.
to operate a conventional transradial
(Courtesy of Hosmer Dorrance Corp, Campbell, CA)
prosthesis due to inadequate strength,
range, or load surface on the residual
lin1b. W ith residual limb-activated
locking hinges, the transradial pros-
thesis is controlled as if it were an el-
bow disarticulation prosthesis with
outside locking hinges (Figure 35) .
Because there is no forearm to func-
tionally use for elbow flexion, a split-
housing dual-control cable system
m ust be provided in which gleno-
A humeral flexion causes elbow Oexion.
Figure 34 A, Geared step-up hinges. B, Sliding action step-up hinges. C, Transradial A split socket is created so that the
prosthesis with step-up hinges demonstrates the split-socket configuration. (Courtesy short residual limb can lock and un-
of Hosmer Dorrance Corp, Campbell, CA) lock the mechanical elbow joint. Re-

sidual limb-activated locking hinges

are available in t\.vo sizes, adult and
small.
Elbow Units for Elbow,

Transhumeral, and
Below-Shoulder
Disarticulation Amputees
Replacement of the anatomic elbow
A :
joint requires a body-powered substi-
tute that permits flexion and exten- Figure 35 A, Residual limb- activated locking hinge. B, Transradial prosthesis with
sion control through a range of ap- residual limb-activated locking hinge. (Courtesy of Hosmer Dorrance Corp, Campbell,
proximately 135°. ln addition, the CA)
unit must permit the amputee to lock
and unlock the elbow at various
points throughout the 135° range of
motion.
Outside-Locking Hinges
Elbow disarticulation and transcondy-
lar levels of amputation usually re-
quire the use of outside-locking
hinges. Standard prosthetic elbow
units would result in an excessively
long humeral section and shortened
forearm segment, creating an unnatu- A
ral appearance. Significant elbow cen- Figure 36 A. Outside-locking hinge. B, Elbow disarticulation prosthesis with outside-
ter discrepancies may also make table- locking hinges. (Courtesy of Hosmer Dorrance Corp, Campbell, CA)
top activities more difficult.
Outside-locking hinges are avail-
able in standard and heavy-duty
models (Figure 36). The standard
units provide seven different locking
positions throughout the range of
flexion and come in adult, medium,
and child sizes. The heavy-duty model
provides five locking positions and is
variable only in the adult size. Figure 37 A, Transhumeral
patient using inside-locking
Inside-Locking Elbow Units elbow. B, Adult size inside-
Amputations through the humerus locking elbow. C, Medium size
elbow. D, Small size elbow.
approximately 5 cm proximal to the
(Courtesy of Hosmer Dorrance
elbow joint provide adequate space to Corp, Campbell, CA)
accommodate inside-locking elbow
mechanisms. Inside-locking units per-
mit the amputee to lock the elbow in
any of 11 positions of flexion (Figure
37). Heavy-duty versions are available
that reduce the number of locking po-
sitions to eight. All inside-locking
units incorporate a friction-held turn-
table that permits manual preposi-
tioning of the prosthetic forearm to
substitute for the loss of active exter-
nal and internal humeral rotation. B c D

Figure 38 Automatic Forearm Balance Figure 40 Small passive friction elbow.

(AFB) elbow. (Courtesy of Otto Bock Figure 39 Flail-arm hinge "prosthesis" (Courtesy of Hosmer Dorrance Corp,
Healthcare-USA, Minneapolis, MN) for patient with brachia! plexus injury. Campbell, CA)
Otto Bock developed a body- thoses" and contain an oversized require less excursion. Although op-
powered elbow that has been opti- dock-spring mechanism to partially tional, elbow flexion assists are rou-
mized to work with an externally counterbalance the weight of the tinely prescribed, particularly for use
powered terminal device. It can lock forearm (Figure 39) . They may be with heavier terminal devices or hand
and release in an infinite number of used singly or in pairs depending on prehensors (Figure 41).
positions because of its friction dutch the degree of counterbalance desired. Otto Bock has developed a spring-
design. This locking mechanism also They may also be combined with a loaded cam mechanism mounted
allows a unique "slip-stop" function. single free joint or a single locking within the forearm that can be ad-
Pulling the control cable a few milli- joint as necessary. justed to completely counterbalance
meters fully locks or unlocks the el- Another type of brachia! plexus the weight of the forearm-wrist-
bow. Pulling the cable very slightly hinge uses the same action as a beach terminal device assembly during el-
"slips" the dutch so that gravity gen- lounge chair; the elbow is ratcheted bow flexion (Figure 38). While the
tly lowers the forearm. When the fore- into position and released with full Automatic Forearm Balance unit
arm reaches the desired position, the flexion. This version uses one small works well with a body-powered cable
amputee simply relaxes the cable ten- medially mounted upright to support that actively flexes the elbow, it can
sion, and the elbow immediately locks the arm. also be adjusted so that the amputee
the forearm in that position. These can simply swing the forearm into
body-powered elbows are also well Friction Units position by throwing the prosthesis
suited for use with proximal elec- Friction elbows are very lightweight forward and then activate the clutch
tronic or myoelectric connections and simple to operate but require lock to stabilize it.
that are prerouted inside the forearm- passive positioning of the forearm
turntable assembly, with distal con- (Figme 40). For tlus reason, they are
nections for the hand and battery often appropriate for cosmetic resto-
Shoulder Units
(Figure 38). rations, pediatric applications, con- Shoulder mechanisms may be classi-
Other elbows have been designed genital anomalies, and situations fied according to the degree of mo-
with reciprocal flexion locking action in which brachial plexus injury or tion allowed. The simplest design is
that also includes a humeral rotation other factors preclude active elbow called a bulkhead because the hu-
unit. This is operated by twisting the function. meral segment is directly connected
ring at the base of the turntable to to the socket and no motion can oc-
unlock transverse rotation, which Elbow Flexion Assists cur. Many unilateral amputees find
then has an adjustable friction con- The spring-lift assist is a dock-spring this acceptable and appreciate the
trol. An opposite twist again locks the unit, similar to the flail-arm hinge, lower prosthesis weight that results
elbow rotation into place. The attach- that can be added to a body-powered from omitting thls joint.
ment ring comes in five configura- elbow. The function of the spring-lift Passively moveable friction- loaded
tions, with the. adult-size diameter at assist is to partially counterbalance shoulder joints are available and pro-
70mm. the weight of the prosthetic forearm vide some assistance with dressing
and reduce the force necessary for el- and desktop activities. Single-axis
Flail-Arm Hinges bow flexion. Reduced force require- units permit only abduction; double-
Flail-arm hinges are intended for ments may permit subtle harnessing axis units allow abduction and flexjon
postbrachial plexus injury "pros- adjustments so that the amputee will (Figure 42); and triple-axis (Figure

Chapter 9: Body-Powered Compon ents 129
Figure 42 Flexion abduction joint with Figure 43 Universal shoulder joint uses
passive friction control for shoulder a friction wrist proxima lly and distally to
motion. (Courtesy of Hosmer Dorrance allow glenohumeral rotation. (Courtesy
Corp, Campbell, CA) of Hosmer Dorrance Corp, Campbell, CA)
Figure 41 A, Spring-lift assist device

w ith internal clock-spring unit. B,
Patient with lift assist mounted medially
on elbow axis. (Courtesy of Hosmer
Figure 44 Locking shoulder joint.
(Courtesy of Liberating Technologies, Figure 45 Nudge control unit can be
Inc, Holliston, MA) used as a control alternative to lock and
43) and ball-and-socket configura-
tions permit universal passive mo- unlock the elbow or shoulder joint.
tion. Most are available in small, me- Campbell, CA)
dium, and large sizes. sion. It is usually prescribed when
A locking shoulder joint is cur- other body motions are not available.
rently available that can stabilize the Although originally designed to pro-
shoulder in 36 different flexion posi- vide elbow locking and unlocking, it
tions. This is beneficial for those who can also be adapted to operate other
wish to use the body-powered or ex- components, including flexion and
ternally powered terminal device for rotation wrist units (Figure 45).
upper quadrant activities such as
reaching items on a high shelf. This
shoulder can be locked and unlocked Endoskeletal Upper
manually or by using an electronic Limb Prostheses
switch option. A second hinge with
friction control is integrated into this Two different endoskeletal upper limb
unit to provide abduction/adduction prosthetic systems are currently avail-
stabilization (Figure 44) . able in the United States. The systems
consist of tubular humeral and fore- Figure 46 Endoskeletal construction,
showing ball-and-socket shoulder joint
arm elements, and the components with foam cover. (Courtesy of Otto Bock
Nudge Control Unit allow for encasement in cosmetic Healthcare-USA, Minneapolis, MN)
The nudge control unit is a paddle- foam covers. After final shaping and
shaped lever that can be pushed by covering with a skin-colored stocki-
the chin or phocomelic digit or nette, the completed prosthesis af- improved cosmesis and softness,
against environmental objects to pro- fords a high degree of cosmetic ac- modular prostheses are lighter weight
vide a small amount of cable excur- ceptability (Figure 46). In addition to thru1 conventional artificial lin1bs.

A B c D
Figure 47 Endoskeletal system
components. A, Shoulder joint,
B, Turntable attachment.
C, Endoskeletal pylon
D, Reciprocating elbow.
E, Pushbutton unlock elbow.
F, Foam cover before shaping.
G, Endoskeletal wrist. (Courtesy of
Hosmer Dorrance Corp, Campbell,
CA)
E
One endoskeletal design permits this endoskeletal prosthesis offers two hand is chosen. A separate wrist unit
passive or cable-operated elbow flex- friction-loaded, passively positionable that fits within the tubular construc-
ion with manual locking. Passive shoulder units, a ball-and-socket tion allows for manual prepositioning
prepositioning of the humeral seg- joint, and a flexion-extension, abduc- of the terminal device in flexion.
ment in internal or e>..1:ernal rotation tion-adduction hinge. Three elbow units are available for
and the forearm in supination or pro- Another system includes compo- either cable-controlled or manual
nation is achieved by the use of rota- nents for transradial, transhumeral, operation- a constant-friction elbow,
tion adapters. The hands provide a and shoulder disarticulation levels of an elbow with manual lock, and an
wide variety of terminal device amputation (Figure 47). Socket at- elbow joint with a cable-controlled
options-cable-controlled, voluntary- tachment turntables permit passive locking mechanism. For the shoul-
opening or voluntary-closing w1its, rotation of the humeral and forearm der disarticulation level, a flexion -
and a passive hand unit with a segments. All terminal devices with e:x:tension, abduction-adduction hinge
spring-activated thumb and fingers. the standard Yl-in-20 thread can be that can be positioned manually is
For the shoulder disarticulation level, used, but usually a cosmetic passive available.

Harnessing and Controls for
Body-Powered Devices
Introduction
In body-powered upper limb pros- type configuration. The amputee uses A) . When cable tension is relaxed, the
thetic applications, the main func- shoulder motion on the amputated movable finger closes on the station-
tions of control and suspension are side to apply tension to the control ary finger (Figure 2, B) . With this type
closely interrelated. The prosthesis is cable. T he cable tension is transmit- of device, the force of prehension is
suspended on the residual limb by the ted to the operating lever, or "thumb," determined by the number of rubber
intimacy of the socket fit and by a of the terminal device and causes one bands located at the bases of the hook
system of nonelastic straps collec- finger of the hook to move away from fingers. As a general rule, each rubber
tively referred to as a harness. In a the other stationary finger (Figure 2, band produces approximately 0.45 kg
well-designed harness, the straps are
strategicaUy positioned in relation to
the shoulder girdle and/or thorax so
that the amputee can control the
prosthetic components with a mini-
mum of exertion and body motion.
To understand the two main func-
tions of a prosthetic harness, it is first
necessary to examine the mechanical
operating principles of prosthetic
control systems.
A
M echanics of the
Transradial Control
System
The transradial prosthetic control
system is a one-cable, or "single-
control:' system. A stainless steel con-
trol cable is firmly attached at its
proximal end to one of the nonelastic
B
straps of the harness (Figure 1). Dis-
tally, the cable terminates at some
type of prehension device. Figure 2 Prehension device with the ca-
Prehension devices, usually re- Figure 1 Transradial prostheti c control ble t ensed (A) and w it h the cable re laxed
system. (Reproduced with permission (B). (Reproduced with permission fro m
ferred to as terminal devices, typically Below and Above Elbow Harness and
from Below and Above Elbow Harness
consist of either prosthetic hands and Control System. Evanston, IL, North- Control System. Evanston, IL, Northwest-
with one or more movable fi ngers or western University Prosthetic-Orthotic ern University Prosthetic-Orthotic Center;
two-fingered devices with a hook- Center; 1966.) 1966.)

Figure 3 Control cable housing.

(Reproduced with permission Figure 4 The length of the control cable
from Below and Above Elbow remains constant. (Reproduced with per-
Harness and Control System. mission from Below and Above Elbow
Evanston, IL, Northwestern Uni- Harness and Control System. Evanston, IL,
versity Prosthetic-Orthotic Cen- Northwestern University Prosthetic-
ter; 1966.) Orthotic Center; 1966.)
Figure 5 Figure-of-8 configuration of a

standard transradial harness·. (Repro-
duced with permission from Santschi WR
(ed): Manual of Upper Extremity Pros-
thetics, ed 2. Los Angeles, CA, University
of California Department of Engineering,
1958.)
( 1 lb) of prehensile force between the

Figure 6 Axilla loop. (Reproduced from Figure 7 Anterior support strap. (Repro-
hook fingers. Pursley RJ: Harness patterns for upper- duced from Pursley RJ: Harness patterns
Most of the control cable is en- extremity prostheses, in Orthopaedic for upper-extremity prostheses, in Ortho-
cased in a flexible stainless steel hous- Appliances Atlas. Chicago, IL, American paedic Appliances Atlas. Chicago, IL,
ing (Figure 3). At its upper end, the Academy of Orthopaedic Surgeons, American Academy of Orthopaedic Sur-
1960.) geons, 1960.)
housing through which the control
cable passes is attached to the triceps
pad of the prosthesis by a fixture amount of body motion used to oper-
called a crossbar assembly. A base ate the terminal device remains essen- bing. The webbing is arranged to form
plate and retainer serve to anchor the tially the same whether the elbow is a horizontally oriented figure-of-8
distal end of the cable housing at ap- flexed to 135° or is completely ex- pattern (Figure 5). The axilla loop,
proximately the midforearm level of tended (Figure 4) . which serves as the primary anchor
the prosthesis. from which two other straps originate,
The cable ~ousing is an integral Figure-of-8 encircles the shoulder girdle on the
part of the transradial single-control nonamputated side (Figure 6).
system. In effect, the housing main- Transradial Harness The second component of the
tains a constant length of the control The standard transradial harness for transradial harness is the anterior
cable regardless of the angular atti- the adult unilateral amputee is com- support strap or, as it is sometimes
tude of the anatomic elbow joint. The posed of 2.5- cm-wide nonelastic web- called, "the inverted Y suspensor." The

Chapter 10: Harnessing and Controls fo r Body-Powered Devices 133
Figure 8 Control attachment strap. (Re- Figure 9 Cross point of a harness sewn Figure 10 Cross point of a harness con-
produced from Pursley RJ: Harness pat- together. (Reproduced from Pursley RJ: nected by a stainless steel ring. (Repro-
terns for upper-extremity prostheses, in Harness patterns for upper-extremity duced with permission from Below and
Orthopaedic Appliances Atlas. Chicago, prostheses, in Orthopaedic Appliances Above Elbow Harness and Control Sys-
IL, American Academy of Orthopaedic Atlas. Chicago, IL, American Academy of tem. Evanston, IL, Northwestern Univer-
Surgeons, 1960.) Orthopaedic Surgeons, 1960.) sity Prosthetic-Orthotic Center, 1966.)
\
Figure 11 Glenohumeral joint flexion for operating a terminal device. (Reproduced Figure 12 Biscapular abduction for ter-
with permission from Below and Above Elbow Harness and Control System. Evanston, IL, minal device operation.
Northwestern University Prosthetic-Orthotic Center, 1966.)
slightly toward the nonamputated

anterior support strap ongmates at scapular abduction and shoulder flex- side. 'When sufficient excursion is
the axilla loop, passes over the shoul- ion on the amputated side for c;>pera- available, most amputees prefer a
der on the amputated side, and at- tion of the terminal device. slightly looser harness with the cross
taches to the anteroproximal margins The posterior junction of the axilla point located at the midline.
of the triceps pad of the prosthesis loop, where the anterior support and The primary body control motion
(Figure 7). The primary function of control attachment straps cross, may for operating the terminal device of a
the anterior support strap is to resist be either sewn together (Figure 9) or transradial prosthesis is flexion of the
displacement of the socket on the re- connected by a stainless steel ring
glenohumeral joint (Figure 11), which
sidual limb when the prosthesis is (Figure 10). In the latter case, the har-
enables excellent generation of force
subjected to heavy loading. ness is referred to as a transradial,
and provides sufficient cable travel for
The control attachment strap orig- ring-type harness. Because they are
less restrictive, ring-type harnesses en- full terminal device operation. When
inates at the axilla loop and terminates
joy a high degree of acceptability by terminal device operation in a fixed
at the proximal end of the prosthetic
most transradial amputees. Whether position or close to the midline of the
control cable (Figure 8). Anchored by
the ax:illa loop, the control attachment the harness straps are sewn together or body is required, such as when button-
strap acts as an extension of the con- attached to the axilla loop by a steel ing a shirt, the sta11dard transradial
trol cable. Located between the spine ring, mechanical efficiency is en- harness permits the amputee to use
and the inferior angle of the scapula, hanced if the cross point is located be- biscapu]ar abduction for terminal de-
the control attachment strap permits low the spinous process of C7 and vice operation (Figure 12).

Medial the prosthesis is distributed over the

loop
suspensor
shoulder on the amputated side
rather than being transmitted to the
ax:illa on the nonamputated side. This
redistribution of loading is accom-
plished by fitting a fairly wide flexible
shoulder saddle on the amputated
side. Two support straps extend from
the posterior portion of the shoulder
saddle through D-rings located on the
medial and lateral surfaces of the tri-
ceps pad and terminate on the ante-
rior surface of the saddle. The shoul-
der saddle is anchored in place with a
Figure 13 Shoulder saddle harness. (Re- Figure 14 Location of the control attach- chest strap. Because the control at-
produced with permission from Santschi ment strap on a shoulder saddle harness. tachment strap is located in essen-
WR (ed): Manual of Upper Extremity (Reproduced with permission from Sants- tially the same place as in the figure-
Prosthetics, ed 2. Los Angeles, CA, Univer- chi WR (ed): Manual of Upper Extremity of-8 harness, the midscapular level,
sity of California Department of Engi- Prosthetics, ed 2. Los Angeles, CA, Univer-
neering, 1958.)
the amputee uses glenohumeral flex-
sity of California Department of Engi-
neering, 1958.) ion and/or scapular abduction for ter-
minal device operation (Figures 13
and 14).
Bilateral Transradial
Harness
The harness pattern for the bilateral
transradial amputee differs only
slightly in that the axilla loops are
omitted. Viewed from the rear, the
control attachment strap for opera-
tion of the right terminal device ex-
tends obliquely upward across the
back and terminates as the anterior
support strap for the left prosthesis
(Figure 15). Conversely, the control
Figure 15 Bilateral transradial harness. Note the location of t he control attachment attachment strap for operation of the
strap in the back view. (Reproduced with permission from Santschi WR (ed): Manual of left terminal device becomes the ante-
Upper Extremity Prosthetics, ed 2. Los Angeles, CA, University of California Department rior support strap for the right pros-
of Engineering, 1958.)
thesis. As in the case of the standard
unilater~ harness, the posterior cross
Heavy-Duty of time, this excessive pressure in the point may be sewn together or con-
axillary area may cause skin irritation nected by a stainless steel ring. The
Transradial Harness and can produce neurotrophic bilateral transradial amputee uses the
A major disadvantage of the standard changes from brachia! plexus pres- same body control motions, gleno-
figure-of-8 harness for transradial sure. When it is anticipated that the humeral flex:ion and/or biscapular ab-
amputees relates to the axilla loop. transradial amputee will engage in duction, for terminal device opera-
The axillary portion of the loop very strenuous activities, particularly tion as does the unilateral transradial
should always be padded and worn on the repeated lifting of heavy objects, it amputee.
top of an undergarment. However, is recommended that a different trans-
when significant tension is applied to radial harness system be considered. Transradial Harness
the anterior support and control at- One alternative transradial harness
tachment straps, the loop is driven is generally referred to as a "heavy- Modifications
vertically upward into the axilla on duty" or "shoulder-saddle" harness. For amputees with a short transradial
the nonamputated side. Over a period With this harness, tension loading on amputation, step-up hinges may be

Chapter l 0: Harnessing and Controls for Body-Powered Devices 135
used with a split socket to provide a

2:1 ratio of elbow flexion to socket
motion, but this configuration re-
quires the amputee to use approxi-
mately twice as much force to flex the
prosthetic forearm. Because split
sockets are used only at very short
transradial levels of amputation, the
extra force required may cause con-
siderable discomfort on the volar or
radial surfaces of the remaining por-
tion of the forearm. For these ampu-
tees, a relatively simple control system
modification may be used to mini-
mize discomfort and facilitate elbow
Figure 16 Modification of the cable housing in a transradial harness. (Reproduced from
flexion. Bechtol CO: Anatomic and physiologic considerations in the clinical application of
The modification consists of split- upper-extremity prosthesis, in Edwards JW (ed): Orthopaedic Appliances Atlas. Ann Ar-
ting the cable housing into proximal bor, Ml, American Academy of Orthopaedic Surgeons, 1960.)
and distal segments similar to those
used for the transhumeral prosthesis.
The proximal piece of housing is at-
tached to the triceps pad and the dis-
tal piece to the prosthetic forearm.
The control cable is now exposed as it
passes anterior to the elbow joint.
Tension applied to the control cable
by glenohumeral flexion on the am-
putated side assists in elbow flexion
(Figure 16).
In some instances, the unilateral
t ransradial amputee can be fit with a
Figure 17 Modified harness to a self-
socket that obviates the need for the
suspending socket. Figure 18 Transhumeral control system.
suspensory function of a harness. Note the use of two cables. (Reproduced
Such self-suspending prostheses are with permission from Below and Above
held on the residual limb by the inti- Elbow Harness and Control System.
Evanston, IL, Northwestern University
macy of the socket fit proximal to the Mechanics of the Prosthetic-Orthotic Center, 1966.)
olecranon and humeral epicondyles
and in the antecubital fossa, or
Transhumeral
through the use of a roll-on liner. Be- Control System
cause these fittings eliminate the need
Transhumeral prostheses are usually
for a triceps pad and anterior support c-
operated by two distinctly separate
strap, the harness consists of a simple
control cables (Figure 18). One cable
axilla loop arow1d the shoulder on
flexes the prosthetic elbow joint and
the nonamputated side. Extending
operates the terminal device, and the
obliquely downward across the ampu-
second cable permits the amputee to
tee's back, the control attachment
lock and unlock the prosthetic elbow.
strap runs from the axilla loop to the
terminal device control cable (Figure Elbow Flexion/Terminal
17). As in the case of the figure-of-8
harness, shoulder flexion and/or scap-
Device Control Cable
ular abduction on the amputated side The housing through which the elbow Figure 19 Split housing for cable in an
Hexion/terminal device cable passes is elbow flexion/term inal device. (Repro-
are the control motions for terminal duced with permission from Below and
device operation. The disadvantage of split into two separate parts (Figure Above Elbow Harness and Control Sys-
this type of harnessing is that long- 19). The proximal portion of the split tem. Evanston, IL, Northwestern Univer-
sleeved clothing is difficult to wear. housing (A) is attached to the poste- sity Prosthetic-Orthotic Center, 1966.)

The ease with which the amputee

can operate the elbow unit and termi-
nal device depends, to a considerable
extent, on the location of the elbow
flexion attachment. Greater force and
less cable excursion are required when
the elbow flexion attachment is clos-
est to the elbow axis. Conversely, a
more distal placement of the attach-
ment requires less force but greater
cable excursion.
B Generally, the longer the residual
limb, the farther the elbow flexion at-
tachment may be placed from the el-
Figure 20 A. Prosthetic elbow flexed using a split cable housing. B, Placing the elbow
f lexion attachment 3 cm distal to t he elbow axis usually is satisfactory, but t he exact lo-
bow axis. Higher transhurneral levels
cation should be determined on an individual basis. (Reproduced with permission from of amputation require a more proxi-
Below and Above Elbow Harness and Control System. Evanston, IL, Northwestern Uni- mal placement of the attachment to
versity Prosthetic-Orthotic Center, 1966.) minimize the excursion required. Al-
though initial placement of the elbow
flexion attachment 3 cm distal to the
elbow axis usually is satisfactory, in
most instances, its precise location
should be determined on an individ-
ual basis (Figure 20).
Elbow Lock Control Cable

The proximal end of the elbow lock
control cable originates at the ante-
rior suspension strap (Figure 21 ).
Passing down the anteromedial sur-
face of the humeral section of the
prosthesis, the distal end of the cable
engages the elbow locking mecha-
nism. The elbow lock works on an
B alternator principle: pull and release
to lock, pull and release to unlock. An
Figure 21 Elbow lock control cable. (Reproduced from Pursley RJ: Harness patterns for excursion of approximately 1.3 cm
upper-extremity prostheses, in Orthopaedic Appliances Atlas. Chicago, IL, American and a force of approximately 0.9 kg (2
Academy of Orthopaedic Surgeons, 1960.) lb) are necessary to cycle the elbow
unit.
rior surface of the humeral section of of the split housing and terminates In summary, the operating se-
the prosthesis. The distal portion of with its attachment at the terminal quence of the two cable systems used
the split housing (B) is fixed to the device (point E). Because the housing with most transhumeral prostheses is
prosthetic forearm by a device called is in two separate pieces and the con- as follows: (1) tension applied to the
an elbow flexion attachment. trol cable passes in front of the elbow elbow flexion/terminal device control
As shown in Figure 19, the elbow axis, tension applied to the cable cable causes the elbow to flex; (2)
flexion/terminal device control cable causes the prosthetic elbow to flex. when the desired angle of elbow flex-
originates at the control attachment The flexion is limited to the gap be- ion is achieved, the rapid sequential
strap of the harness (point C) . Passing tween the two cable housings. application and release of tension on
through the proximal portion of the Split housing systems provide se- the elbow lock control cable locks the
split housing, the control cable is ex- quential control because cable excur- elbow; and (3) with the elbow locked,
posed anterior to the mechanical el- sion results first in elbow flexion. the reapplication of tension on the
bow axis (point D). The elbow Once the elbow unit is locked, further elbow flexion/terminal device control
flexion/terminal device control cable cable excursion operates the terminal cable permits operation of the termi-
continues through the distal portion device. nal device (Figure 22).

Chapter 10: Harnessing and Controls for Body-Powered Devices 137
Figure-of-8
Transhumeral
Harness
Although the full operation of the
terminal device of a transradial pros-
thesis requires only 5 cm of cable ex-
cursion, more than twice that amount
of excursion is required for full elbow
and terminal device operation of a
transh umeral prosthesis. Conse- Figure 22 Reapplication of tension on
quently, great attention must be paid the elbow f lexion/terminal device control
to the details of fitting the trans- cable permits operation of the terminal
Figure 23 The . posterior intersection of
device. (Reproduced with permission
humeral harness. Precision in the lo- the harness straps (arrow) should ideally
from Below and Above Elbow Harness
cation of the harness and control sys- and Control System. Evanston, IL, North- be positioned toward the nonamputated
tem components is essential for side of the bod y. (Reproduced from Purs-
western University Prosthetic-Orthotic
ley RJ: Harness patterns for upper-
achieving satisfactory comfort and Center; 1966.)
extremity prostheses, in Orthopaedic
function . Appliances Atlas. Chicago, IL, American
Like the standard transradial har- Academy of Orthopaedic Surgeons,
The anterior support strap serves 1960.)
ness, the transhumeral harness typi- several fw1ctions in the transhumeral
cally consists of a system of intercon- harness system. Anchored to the axilla
nected nonelastic and elastic straps loop posteriorly and to the humeral
laid up in a figure-of-8 pattern. The section anteriorly, the strap helps to
common elements of the standard best prosthetic suspension and con-
suspend the prosthesis against axial trol. To maintain a fairly snug axilla
transhumeral harness are the axilla loading. However, because the antero-
loop, anterior and lateral support loop, the posterior intersection of the
distal two thirds of the strap consists harness straps should be positioned
straps, control attachment strap, and of elastic webbing, suspensory func-
elbow lock control strap. The axilla slightly toward the nonamputated
tion is limited. side of tl1e body (Figure 23).
loop acts as the fixed anchor from A second function of the anterior
which other harness components support strap is to help prevent ro- Lateral Support Strap
originate. Some of the straps originat- tation of the prosthetic socket on the The lateral support strap shown m
ing at the axilla loop serve to suspend residual limb during prosthetic use. Figure 24 is the primary suspensory
the prosthesis on the residual limb, The transhumeral amputee uses element of the harness. Originating
while others provide the an1putee glenohumeral flexion on the ampu- posteriorly from the upper portion of
with volitional control of the pros- tated side to flex the prosthetic elbow the axiJla loop, the strap is directed
thetic components. and/or operate the terminal device. horizontally and stitched to the ante-
Because the proximal control cable rior support strap at the points
Anterior Support Strap
housing is attached on the posterolat- marked A and B. The lateral end of
The anterior support strap, some- eral surface of the humeral section of the strap passes just anterior to the
times referred to as the elastic suspen - the prosthesis, glenohumeral flexion acromion and is attached close to the
sor, originates at the axilla loop (Fig- tends to result in external rotation of proximal trim line of the prosthetic
ure 21, A). Passing over the shoulder the socket on the residual limb. The socket at the point marked C. In addi-
on the amputated side, the strap con- anterior support strap running down- tion to its suspensory function, the
tinues down the anteromedial surface ward mediolaterally resists this rota- strap helps to prevent external rota-
of the humeral section of the prostl1e- tion. tion of the socket on the limb when
sis. The anterior support strap termi- tension is applied to the elbow
nates with its attachment on the ante- Axilla Loop flexion/terminal device control cable.
rior surface of the prosthetic socket Working as a key element of the en-
slightly proximal to the mechanical tire harness, the axilla loop should en- Control Attachment Strap
elbow joint (Figure 21, B). When circle and fit the shoulder on the non- The control attachment strap origi-
viewed from the front, it should be amputated side as securely as nates at the posterior intersection of
noted that the distal two thirds of the possible. A small, snug axilla loop, the axilla loop. Running obliquely
anterior support strap consists of one that does not compromise ampu- downward across the amputee's back,
elastic webbing. tee comfort excessively, provides the the control attachemnt strap terrni-

position requires the amputee to use

unnecessarily forceful shoulder flex-
ion for fuU operation. With the con-
trol attachment strap located at
approximately the midscapular level,
midway between the spine and in-
ferior angle, the amputee usually will
be able to achieve full operation of
the components using a moderate
amount of force.
Cross-Back Strap
A cross-back strap is sometimes used
as an adjunct to the figure-of-8
transhumeral harness (Figure 26) .
Originating at the axilla loop close to
the posterior axillary fold, the cross-
back strap passes horizontally across
the amputee's back and terminates at
the distal end of the control attach-
Figure 24 Location of the lateral support strap in a f igure-of-8 transhumeral harness. ment strap. Indications for the use of
(Reproduced from Pursley RJ: Harness patterns for upper-extremity prostheses, in Ortho-
this strap relate primarily to amputee
paedic Appliances Atlas. Chicago, IL, American Academy of Orthopaedic Surgeons,
1960.)
comfort and ease of prosthetic opera-
tion.
At midhumeral and higher levels
of transhumeral amputation, it be-
comes increasingly important that the
harness be fitted as intimately as pos-
sible. Because a snug harness fit re-
qu.ires a relatively small axilla loop,
the loop may cause axillary discom-
fort on the nonamputated side. This
discomfort is caused by vertical com-
pression of the pectoral, teres major,
and latissinrns dorsi tendons by the
ax:iUa loop during strenuous pros-
thetic usage. The use of a cross-back
strap in such instances helps to re-
Figure 25 Location of the control attach- Figure 26 Cross-back strap (arrows) used duce the magnitude of the vertically
ment strap in a figure-of-8. t ranshumeral as an adjunct to a standard t ranshumeral directed force created by a snug axilla
harness. (Reproduced from Pursley RJ: harness. (Reproduced from Pursley RJ: loop.
Harness patterns for upper-extremity Harness patterns for upper-extremity
Another indication for the addi-
prostheses, in Orthopaedic Appliances At- prostheses, in Orthopaedic Appliances At-
las. Chicago, IL, American Academy of las. Chicago, IL, American Academy of tion of a cross-back strap is when the
Orthopaedic Surgeons, 1960.) Orthopaedic Surgeons, 1960.) posterior intersection of the harness
rides too high on the amputee's back.
With the posterior intersection of the
nates with its direct attachment to the The proper location of the control harness on or superior to the spinous
elbow flexion/terminal device control attachment strap as it passes from the process of C7, the amputee is uncom-
cable (Figure 25) . With the control axilla loop to the elbow tlexion/ fortable, and the work efficiency of
attachment strap firmly fixed at its terminal device control cable is im- the entire harness and control system
proximal end by the axilla loop, it is portant. If the control attachment is diminished. The cross-back strap
easy to visualize how shoulder flex:ion strap lies too high on the amputee's helps to maintain the posterior inter-
on the amputated side creates both back, shoulder flex:ion will not prosection of the harness below the
the cable tension and cable excursion duce sufficient cable excursion for full spinous process of C7.
required for elbow flex:ion and operation of the mechanical elbow As noted earlier in this chapter, the
terminal device operation. and terminal device. Too low a strap split housing transhumeral prosthetic

control system requires approxi- strap serves to complete the lock/

mately 11.3 cm of cable excursion for wtlock cycle.
full elbow and terminal device opera-
tion. Whether or not the amputee is Special .Considerations
able to generate this much cable ,ex- Th~ ring-type harness does not offer
cursion depenas to a great extent on the same degree of function in
the path of the control attachment transhumeral harnessing as it does at
strap as it crosses the amputee's back. the transradial level. At midhumeral
Ideally, the path of the strap should and higher levels of amputation, it
run between the spine and inferior becomes increasingly impottant that
angle of the scapula. Cable excursion, the h1rness fit as snug as possible.
normally produced by glenohumeral Ring-type harnesses do not permit
flexion on the amputated side, the same degree of tautness in the
diminishes as the path of the control
straps of the system as do stitched
attachment strap moves closer to the
harnesses. Consequently, at the higher
shoulder joint. The addition of a
transhumeral levels, the ring-type Figure 27 Elbow lock control strap (ar-
cross-back strap helps to keep the
path of the control attachment strap harness does not provide a very high row) on a transhumeral harness. (Repro-
degree of positive control of the pros- duced from Pursley RJ: Harness patterns
positioned lower on the back. for upper-extremity prostheses, in Ortho-
Cross-back straps may be made of thetic components wtless the straps
paedic Appliances Atlas. .chkago, IL,
either elastic or nonelastic webbing. are sewn in place after adjustment. American Academy of Orthopaedic Sur-
The nonelastic strap provides the am- The standard figure-of-8 harness is geons, 1960.)
putee with more positive control of suitable for and acceptable to most
the prosthetic components and over- unilateral transhumeral amputees.
The harness for the bilateral trans-
all tautness of the harness. An elastic However, the unilateral transhumeral
humeral amputee consists of two
strap provides less positive control amputee who engages in unusually
figure-of-8 harnesses without axilla
but greater degrees of comfort and strenuous physical activity on a regu-
loops (Figure 29). The control attach-
mobility of the shoulder girdle. lar basis may find the standard har-
ment strap for the right prosthesis
ness uncomfortable. During periods
Elbow Lock Control Strap passes over tl1e amputee's left shoul-
of heavy work, the relatively narrow der and becomes the anterior support
The elbow lock control strap origi- straps tend to subject the soft tissues strap for the left prosthesis. Likewise,
nates at the upper, nonelastic portion over which they pass to inordinately the left control attachment strap be-
of the anterior support strap and is high unit pressures. Particularly vul- comes the right anterior support
attached at its distal end to the elbow nerable are the skin, tendons, and strap. At their intersection in the mid-
lock control cable (Figure 27). To ei- neurovascular structures of the axilla line of the amputee's back, the two
ther lock or unlock the prosthetic el- on the nonamputated side. The prob-
bow, the an1putee must first apply straps are sewn together. As in the
lem -is further compounded at the unilateral harness system, the elbow
tension and then, in rapid sequence, transhumeral level because maximal
relax tension on the elbow lock con- lock control straps of the bilateral
control of the components of the harness originate on the nonelastic
trol cable. Although the cable excur- prosthesis requires the use of a small,
sion requirement for prosthetic elbow portion of the anterior support strap.
snug axilla loop. The lateral support straps consist of a
operation is small, approximately 1.3
Alleviation of axillary discomfort continuous piece of nonelastic web-
cm, the body motion is somewhat
for the transhumeral amputee may bing attached close to the proximal
complex. The amputee applies ten-
sometimes be achieved through the trimlines of both sockets and pass
sion to the elbow lock control strap
and cable by slight extension and abuse of a shoulder saddle harness. The slightly anterior to the acromion pro-
duction of the glenohumeral joint, transhumeral shoulder saddle harness cesses. Posteriorly, the lateral support
combined with equally slight shoul- distributes tension Joadi11g on the straps are stitched to the anterior sup-
der depression on the amputated side. prosthesis to the shoulder on the am- port straps. Whereas a cross-back
This motion, in addition to exerting putated side. Because the control at- strap is considered optional in the
tension on the elbow lock control tachment and elbow lock control standard unilateral transhumeral har-
strap and cable, also stretches the straps run along the same paths as ness, it is an essential component in
elastic portion of the anterior support they do in the standard harness, tl1e the bilateral harness. As seen in Figure
strap. With the rapid return of the body control motions for prosthetic 29, the cross-back strap runs horizon-
prosthesis to the starting position, the operation remain essentially un- tally between the two control attach-
elastic tension of the anterior support changed (Figure 28). ment straps. The over-the-shoulder
.. American Academy of Orthopaedic Surgeons

,..
d uction for elbow flex:ion and termi- q

nal device operation. Elbow lock
control is achieved with slight gleno- S•
humeral extension and abduction ti
combined with shoulder depression. 3
Two major problems confront the bi- r.
lateral amputee with this type of har- c
ness. First, the amputee will encoun- r
ter some difficulty in operatu1g both s
prostheses simultaneously. Tension t
applied to both elbow flexion/
terminal device cables permits open-
ing (or closing) of both terminal de-
vices, but both terminal devices
cannot be operated to effect simulta-
neous opening and closing on oppo-
Figure 28 Transhumeral shoulder saddle h arness. (Reproduced from Pursley RJ: Harness site sides without relaxing tension on
patterns for upper-extremity prostheses, in Orthopaedic Appliances Atlas. Chicago, IL,
one of the cables. Consequently, the
American Academy of Orthopaedic Surgeons, 1960.)
possibility of active bimanual manip-
ulation of objects is minimal. A sec-
ond major deficiency of this harness
system is that it does not permit the
amputee to lift any significant
amount of weight in the terminal de-
vice of either prosthesis.
One approach to overcome some
of these limitations may be to provide
ru1 externally powered prosthesis on
one side and a body-powered device
on the other. Providing prostheses
with differing control systems usually
permits independent operation of
one or both artificiaJ arms.
Shoulder
Disarticulation
Harness
Figure 29 Harness for a bilateral t rans- Figure 30 Harness for a bilateral trans- At the shoulder disru·ticulation level
humeral amputee (posterior view). (Re- humeral amputee (anterior view). (Repro- of amputation, the absence of gleno-
produced from Pursley RJ: Harness pat- duced from Pursley RJ: Harness patterns
humeral flexion as a control source
terns for upper-extremity prostheses, in for upper-extremity prostheses, in Ortho-
Orthopaedic Appliances Atlas. Chicago, paedic Appliances Atlas. Chicago, IL, requires the use of other body mo-
IL, American Academy of Orthopaedic American Academy of Orthopaedic Sur- tions for prosthetic operation. Biscap-
Surgeons, 1960.) geons, 1960.) ular abduction is, at least for most
adult male amputees, the best avail -
able body motion for generating suf-
ficient cable tension to flex the elbow
straps complete the figure-of-8 har- the amputee's shoulder. The over-the- and operate the terminal device of the
ness for the bilateral transhumeral shoulder straps terminate anteriorly prosthesis. It should be noted,
amputee. by attachment to the nonelastic por- however, that many people with high-
At their posterior origins, the over- tions of the anterior support straps level amputations cannot generate
the-shoulder straps are sewn to the (Figure 30). sufficient excursion or strength to op-
control attachment straps. The straps T he bilateral transhumeral harness erate a fully body-powered system.
are also stitched to the lateral support permits the amputee to use gleno- Therefore, the use of externally
straps at a point before they pass over bwneral flex:ion and/(?r scapular ab- powered components is often re-

quired and frequently preferable.

The force generated by active bi-
scapular abduction is best harnessed
through use of a chest strap (Figure
31, A). Composed of 3.8-cm-wide
nonelastic webbing, the chest strap
originates with a buckle on the ante-
rior surface of the shoulder cap of the
socket. Running horizontally across
the amputee's thorax, the strap passes
immediately inferior to the axilla on
the nonamputated side. The chest
strap terminates posteriorly with its
attachment to the proximal end of the
elbow flexion/terminal device control
cable.
Vertical suspension of the chest
strap and prosthetic socket is aug-
mented by the use of an elastic sus- F_igure 31 A, Chest strap (arrow) on a shoulder disarticulation harness. B, Elastic ante-
rior suspensor chest strap (arrow) on a shoulder disarticulation harness. (Reproduced
pensor strap. The anterior suspensor
with permission from Pursley RJ: Orthop Prosthet Appl J 1955;9:15.)
originates posteriorly on the chest
strap (Figure 31, B) . Passing over the
shoulder on the amputated side along der cap. With this type of amplifier,
a diagonal path, the suspensor termi- each 2.5 cm of cable excursion gener-
nates with its attachment to the prox- ated by biscapular abduction causes
imal surface of the shoulder cap. In the elbow flexion/terminal device
addition to assisting with vertical control cable to move through an
support, the anterior suspensor pre- excursion of 5 cm. Consequently, 5.6
vents external rotation of the socket cm of chest expansion produces the
on the shoulder during use of tthe 11.3 cm of cable excursion required
prosthesis. for full elbow and terminal device
Biscapular abduction is usually operation.
strong enough to produce sufficient It should be noted that although
cable tension for fully operating the
the incorporation of a pulley in the
elbow and terminal device of a shoul-
harness system doubles the cable ex- Figure 32 Excursion amplifier on a shoul-
der disarticulation prosthesis. Abduc- der disarticulation strap. (Reproduced
cursion, it also doubles the input
tion of the scapulae is, however, a with permission from Santschi WR (ed):
force required for elbow flexion
poor body motion for generating ade- Manual of Upper Extremity Prosthetics,
and/or terminal device operation. Be- ed 2. Los Angeles, CA, University of Cali-
quate cable excursion. Very few shoul-
cause biscapular abduction is a good fornia Department of Engineering, 1958.)
der clisarticulation amputees are ca-
pable, through biscapular abduction, source of force generation, this in-
creased force requirement does not
of generating enough cable excursi.on
to permit complete elbow and termi- pose a major problem for some adult
strap as an anterior extension of the
nal device operation. shoulder disarticulation amputees,
chest strap.
Because biscapular abduction is a but others do better with externally
In this method, the anterior at-
good source for generating cable ten- powered components.
tachment of the chest strap is bifur-
sion but a poor source of cable excur- Depending on factors such as body
cated (Figure 33). The upper leg of
sion, an excursion amplifier is some- build, adequate range of scapulotho-
the split strap consists of nonelastic
times provided (Figure 32). A simple racic motion, and the neuromuscular
coordination of the amputee, locking webbing. The lower leg is nonelastic
excursion amplifier consists of a small at its extremities-its origin on the
pulley attached near the posterior end and unlocking of the elbow unit of a
shoulder clisarticulation prosthesis chest strap and attachment on the
of the chest strap of the harness. The
can be performed in one of several socket- but has a segment of elastic
proximal end of the elbow flexion/
different ways. The preferred body- webbing at its center. A nonelastic el-
terminal device cable passes through
the pulley and is attached to the pos- powered method involves the incor- bow lock control strap ongmates at
terior surface of the prosthetic shoul- poration of the elbow lock control the chest strap, passes laterally be-

hr
Auxiliary
return spring
Figure 35 Nudge control (arrow) is an, al- Figure 36 A small, well-padded plastic cap covers the apex of the acromion on t he side
ternative elbow lock control on a shoul- opposite the prosthesis. (Reproduced with permission from Santschi WR (ed): Manual of
der disarticulation prosthesis. (Repro- Upper Extremity Prost hetics, ed 2. Los Angeles, CA, University of California Department
duced with permission from Santschi WR of Engineering, 1958.)
(ed): Manual of Upper Extremity Pros-
t hetics, ed 2. Los Angeles, CA, Univer.sity
of California Department of Engineering, wrist, or hand components. For this excursion. lf the pull switch has a to-
1958.) application, there are two important tal operating range of O to 5 mm, then
requirements tl1at differ from harness the webbing bridge is attached with
configurations that directly operate a just enough slack that limits the har-
the available range of biscapular mo-
body-powered device: (1) minimizing ness pull to a maximum of 6 mm.
tion, thereby preserving the impor-
the excursion generated, and (2) pro- This does not interfere with full vol-
tant control source (Figure 36).
tecting the microswitcb or force sen- untary operation but prevents exces-
Biscapular abduction and the use
sor from force overloads. sive motion from damaging the
of an excursion amplifier may permjt
Because it takes less than 10 mm of switch. The second method incorpo-
adequate cable excursion for produc-
movement to operate most mi- rates a segment of elastic webbing in
ing a reasonable degree of elbow flex-
croswitch or force sensors, there is no the control strap, often in combina-
ion and terminal device operation.
need to generate additional excmsion. tion with the nonelastic webbing
Shoulder elevation on the amputated
One of the easiest ways to reduce ex- bridge previously discussed. During
side may be used for elbow lock con- extreme movements, the elastic seg-
cursion is to loosen the control strap,
trol. which also increases amputee comment stretches and reduces the stress
Harnessing patterns for scapu- fort. However, care must be taken to on the switch. If the elastic strap is
lothoracic amputation do not differ avoid making the harness so loose too easy to stretch, the amputee is
sigruficantly from those used in the that gross body movements are re- then forced to make a greater move-
shoulder disarticulation, except that quired to actuate the switch. Another ment to operate the control device.
the efficiency of operation is less. way to minimize the excursion is to This usually is considered undesirable
Most persons with high-level amputa- route the control cable through or but can sometimes be an advantage if
tions benefit from the use of exter- near a joint. For example, routing the the patient is having difficulty distin-
nally powered componentry. control cable near the glenohumeral guishing between small switch move-
joint will minimize the excursion gen- ments.
erated by forward humeral flexion for
Harnessing for
transhumeraJ applications. Control
Switch Control of motions with less inherent excursion,
Conclusion
Externally Powered such as shoulder elevation, are partic- A well-designed harness provides sus-
ularly suitable for switch con trol. pension, rotational control, switch
Components There are two principal metl1ods operation, or activation of a body-
Many of the harnesses described in to protect the switch from overloads. powered component. To facilitate pa-
this chapter can be modified to oper- The first method incorporates a seg- tient acceptance, it should also be
ate a microswitch or force sensor to ment of nonelastic webbing that comfortable for the amputee to wear
control electrically powered elbow, bridges the switch and limits the total and sin1ple to don and doff.

hr
Components for Electric-Powered
Systems
O·aig W. Heckathorne, MSc
Introduction
Since the publication of the second shoulder joint. Each section begins sembly that has electronics, generally
edition of the Atlas in 1992, the use with a general description of the com- the preamplifier and filters, along
of prostheses with electric-powered ponents to be covered. Common char- with the metal electrodes used to pick
components has continued to grow. acteristics and features are described, up the surface muscle signals.
Four factors were identified in the and if data are available, comparisons This chapter is intended to be a
1992 edition to explain the increase in are drawn between the device and its component review; therefore, tech-
the number of successful electric- physiologic coLll1terpart. Detailed de- niques for incorporating components
powered fittings over the previous scriptions of available components into prosthetic systems and fabricat-
decade. These factors, which still exert follow, covering construction and me- ing prostheses are not covered. Tech-
a strong influence on the expanding chanical specifications for each device, nical manuals and courses are avail-
use of electric-powered systems, are performance characteristics, control able from the various manufacturers
(1) technologic advances in actuators, systems offered by the manufacturer, for this purpose. Techniques for inte-
materials, and controllers (generally and (if applicable) compatible contrnl grating multiple systems into a single
outside the field of prosthetics); systems offered by other suppliers. prosthesis and for designing hybrid
(2) conceptual advances leading to In the discussions of control op- systems combining body-powered
designs with improved performance tions, a common control terminology and electric-powered componentry
characteristics; (3) a growing body of is used to identify the number of dis- are also not discussed; these areas of
experience guiding successive clinical tinct control sources and distinct de- special ization would warrant separate
fittings; and (4) the willingness of a vice functions. For example, a myo- and detailed treatment. However, in-
diverse community of prosthetists, electric controller might be described tegrated systems that are provided by
engineers, therapists, designers, physi- as providing two-site, n,vo-fw1etion a manufacturer as a specific option
cians, allied health workers, and ex- control. This indicates that two sepa-
are described.
emplary users to share their knowl- rate and independent muscle sites are
edge and experience. required to operate the controller and
This chapter provides an overview that two functions (eg, "open" and Prehension
of upper limb electric-powered com- "close") can be controlled voluntarily. Mechanisms
ponents for adults, emphasizing the The "off" condition is generally as-
design aspects that influence their sumed unless noted otherwise be- Electric-powered prehension devices
performance and use. The devices cause it is not practical for a battery- are available in a variety of forms, not
that are described are limited to com- powered device to remain on all of which resemble the anatomic
ponents that are commercially avail- continuously in the absence of a con- hand. Despite differing appearances,
able and readily obtained in North trol signal. In the case of control by all commercially available electric-
America. means other than muscle signals, or powered prehension devices function
The chapter is organized into five when · myoelectric control is one of in much the same way-with a single
sections-prehension mechanisms, several options, the more general degree of freedom of motion that
wrist mechanisms, enhancements to term source is used rather tha11 site. In brings two (or three) surfaces in op-
body-powered elbows, elbow mecha- discussing myoelectric controllers, position, allowing for the grasping of
nisms, and enhancement of a manual mxoelectrode is used to denote an as- objects. None of the devices offers in-
... American Academy of Orthopaedic Surgeons 145

-
dependent movement of individual gard to control. Fidelity to an ana- General Characteristics of
fingers, and all have fixed prehension tomic shape entails engineering com- Commercial Electric TA
patterns. promises that diminish not only the Prehensors
Early development of electric- prehensile function but also the over- Cer
powered prehension devices empha- all mechanical function of electric
Prebension devices shaped Like hands oa·
are made for the European and North S-1
sized preservation of an anatomic prehensors. 10• 11 The band-like shape sw
appearance. 1•3 This preference grew American markets by Otto Bock
and fixed orientation of the fingers Ho
out of two broad, mutually reinforc- Health Care, CentriAB, Motion Con- 56
make precise tasks difficult to per-
ing considerations. One was a sensi- trol, Inc, and RSLSteeper (Table 1). Car
form; although a special consider- us
tivity to the sociologic, symbolic, and Electric prehensors with nonanatomic
ation with bilateral amputations, this Lit
aesthetic qualities associated with the shapes are made by Otto Bock, Hos-
shortcoming is also cited by persons 32
hwnan hand, qualities that can be mer Dorrance Corporation, Motion He
with unilateral amputations. The abil-
powerful shapers of individual per- Control, and RSLSteeper. Specific us
ity to reorient the electric hand is sig-
ceptions. 4'5 The second consideration characteristics of these devices are
nificantly limited because of the asso- Mc
was a general expectation that .in an provided in Table 2 (hand-like de-
ciated loss of the physiologic wrist in vices) and Table 3 (non-hand-like de-
24
environment of objects manufactured most upper limb amputations, and Sa
to be handled by human hands, a devices). U5
this cannot be compensated by All of the prehensors shaped like Ot
vice with hand-like characteristics
changing the orientation of the fin - hands are configured for palmar pre- Tv,
would offer the· best prehension func- M
gers. The size and shape of the electric hension, tl1e opposition of the distal
tion. This expectation was taken liter-
hand can obstruct the view of the ob- u~
ally, with the adoption of shape as a palmar pad of the thumb with the R5
ject being grasped or the work area in distal palmar pads of tl1e index and Q1
principal characteristic. 6 general. Shape constraints have also middle fingers. Of the prehension Re
These considerations carry just as Re
limited the form and arrangement of patterns identified by Schlesinger, 13
much validity today as in the early Le
structural frames and finger arma- Keller and associates 14 determined S\
years. Although quality of appearance
tures; these parts can be damaged by that palmar prehension predominated U1
can vary considerably, the cosmetic
heavy use. The polyvinyl chloride main the holding of objects for use by
function of a prehensor with a hand-
terial from which most cosmetic the dominant hand. The predomi-
like shape has been shown to be a
gloves are made is more dmable than nance of palmar prehension has also rr
strong determinant of personal
silicone alternatives, but it is suscepti- been demonstrated for grasping by
acceptance.1 · 10 In addition, the broad is
ble to staining from common dyes, the nondomi:nant hand. 15 The persis- c
contact surfaces of the electric-
inks, and other substances. Power is tence of this configuration in pros- ti
powered hand and frictional proper-
lost in compressing and stretching the thetic hand designs and its general ac-
ties of the cosmetic glove offer good
cosmetic plastic forms and gloves en- ceptance over the years supports these
p
grasp and retention of held objects.
The other significant factors cited for closing the mechanisms, contributing observations. F
the acceptance of hand-like prehen- to the degradation of overall perfor- To achieve the palmar prehension t,
sors-higher prehension force, re- mance. pattern, the fingers of electric- 0
duced operating effort, increased These observations have led to in- powered hands are fixed in slight flex- }
comfort associated with the absence creasing recognition that prehension ion at positions approximating the in- I
of control harnessing in myoelectri- devices shaped like hands are most terphalangeal joints. The resulting 1
cally controlled prehensors, and pre- useful if supplemented with other finger shape also creates a concave in- a
hension control independent of the prosthetic devices that have charac- ner prehension surface that is useful
position of the prehensor with respect teristics not constrained by fidelity to for cylindrical grasp. Additionally, the
to the body-are equally applicable to an anatomic shape.3 •10· 12 Use of frictional properties of the entire sur-
electric-powered prehensors not body-powered prostheses with hook- face of the cosmetic glove of the elec-
shaped like hands. type prehensors is frequently cited in tric hand facilitate fixation and stabi-
Electric hand prehensors have not, association with use of electric- lization of objects against surfaces or
however, proved to be the ideal pros- powered prostheses. Adaptors and against tl1e body. 16 The prehension
thetic solution that early develop- tools that can be held within the elec- patterns of prehensors that do not
ments seemed to promise. Almost tric hand and mechanical tools that have a hand-like shape (Table 3) are
four decades of experience with com- can be interchanged with the hand discussed later, in the detailed device
mercial electric hands have under- prehensor are now available. Several descriptions.
scored the technologic limitations of electric-powered prehensors tl1at do Among the mechanical character-
the designs and the deficiencies in our not have a hand-W<e shape are com- istics listed in Tables 2 and 3 are max-
understanding of the physiology of mercially available for use with (or in imum prehension force, maximwn
the human hand, especially with replace of) electric hands. width of opening, and speed of move-

Chapter 11: Components for Upper Limb Electric-Powered Systems 147
prehension force. The frictional prop-

TABLE 1 Manufacturer Contact Information erties of the materials lining the pre-
hension surfaces and the ability of
Centri AB phone: +46 8 580 311 65 these materials to conform to the sur-
Datavagen 6 fax: +46 8 580 811 28 faces of held objects will also influ-
s-175 43 Jarfalla email: centri@centri.se
Sweden website: http://www.centri.se/main.htm ence the effectiveness of the applied
Hosmer Dorrance Corporation phone: 1-408-379-5151 grip force.
561 Division Street fax: 1-408-379-5263 Regulation of the applied force
Campbell, CA 95008 email: customerservice@hosmer.com (below the maximum) is a function of
USA website: http://www.hosmer.com/
the control system of the particular
Liberating Technologies, Inc phone: 1·508-893-6363
325 Hopping Brook Road, Suite A orders: 1-800-437-0024 device and is discussed later, in the
Holliston, MA 01746-1456 fax: 1-508-893-9966 detailed device descriptions. No
USA email: info@liberatingtech.com commercial electronic system pro-
website: http://www.liberatingtech.com
vides direct sensory feedback of ap-
Motion Control, Inc phone: 1-888-696-2767
2401 South 1070 West, Suite B fax: 1-801-978-0848 plied force. Gripping force must be
Salt Lake City, UT 841 19-1555 email: info@utaharm.com estimated indirectly through its effect
USA website: http://www.utaharm.com on the object being grasped, the re-
Otto Bock HealthCare phone: 1-800-328-4058 sponse of the prehensor as force in-
Two Carlson Parkway, Suite 100 fax: 1-800-962-2549
email: info@ottobockus.com
creases, or some relationship between
Minneapolis, MN 55447-4467
USA website: http://www.ottobockus.com the magnitude of the user's control
RSLSteeper phone: 0208 788 8165 signal and the force applied by the
Queen Mary's University Hospital fax: 0208 788 0137 mechanfam.
Roehampton email: sales@rehab.co.uk
Roehampton Lane website: http://www.rslsteeper.com
All of the electric prehensors in-
London clude some mechanism for maintain-
SW15 SPL ing grip force in the absence of a con-
United Kingdom
trol signal and without additional
power to the motor, similar to the
function of a vise. This is an impor-
ment of the fingers. These character- eral prehension, 93.4 N for tip pre- tant feature, essential to the overall
istics merit additional discussion be- hension, and 400 N for cylindrical performance of a prehensor. Without
cause of their significant impact on grasp. 17 More recent reports of larger this feature the motor would need to
the prehensile function of the devices. populations have produced slightly be powered while it is not moving, a
different means but generally support condition of stall. A motor draws high
Prehension Force the earlier study. 18' 19 currents during stall, which would de-
Force, a relatively easy characteristic Another investigation indicated plete a battery supply within a rela-
to quantify, is often cited as a "figure that prehension forces to a maximum tively short time.
of merit" for a prehension device. of 66.7 N were necessary to carry out The same mechanjsm that main-
However, little is known about how a variety of activities of daily living. 20 tains the applied force also prevents
prehension force capacity, frictional Peizer and associates 1 proposed that the fingers from being pried open by
properties of the surfaces in contact, this be a minimum standard for the external forces while an object is
and conformability to surface features maidmum prehension force of an grasped. This feature is certainly help-
contribute to adequate grip. Because electric prehensor, reasoning that ful when using tools and otl1er imple-
changes in either of the latter two higher forces could only improve the ments held in the prehensor. To
characteristics can significantly alter prehensile utility of a prosthetic pre- prevent damage, most prehensors in-
the effectiveness of the applied force, hensor. corporate some method (such as a
force should not be considered in iso- All of the devices listed in Tables 2 clutch) that allows the fingers to open
lation from the other prehensile char- and 3 have specified maximum pre- under excessive external forces. This
acteristics when comparing particular hension forces, some of them ap- method can also be used to force the
devices. proaching or exceeding physiologic fingers open in the event that the pre-
Rationales for force requirements levels and most exceeding the mini- hensor does not respond to an open-
of prosthetic prehensors are typically mum standard proposed by Peizer ing control signal and the user wants
based on physiologic performance. and associates. 1 However, devices ca- to release a held object.
One study of human prehension force pable of achieving high prehension
indicated that adult men could pro- force do not necessarily apply that Width of Opening
duce maximum mean forces of 95.6 N force as effectively or more effectively Studying the handling of common ob-
14
for palmar prehension, 103 N for lat- than a device with a lower maximum jects, Keller and associates deter-
.. American Academy of Orthopaedic Surgeons

p
TABLE 2 Characteristics of Adult Electric-Powered Prehensors: Ha nd-like Devices

DMC Plus System Motion Control MultiControl Plus
Device Electric Hand Centri Electric Hand Hand Electric Hand
Manufacturer
Adu lt sizes available Otto Bock CentriAB Motion Control RSLSteeper
(circumference at 7V., 73/4, 8 1/4 7 1/4, 73/4 7 1/4, 73/4, 8 1/,i 7 V., 7V2, 73/4
knuckles, in inches)
Width across knuckles 7.6, 8.0, 8.9 NfA 7.6,8.1,9.1 7.0, 7.6. 8.3
(in cm)
Circumference at 18.4, 19.7, 21.0 18.4, 19.7 19.0, 19.5, 21.4 19.1 , 20.3, 21.6
knuckles (in cm)
Length * = 14 cm = 7.5 cm (size 7 %) 13.7 cm (size 7314) 13.7 cm (all sizes)
1
Weight 440 g (size 7 1/4) * 250 g (size 73/4) 433 g (size 73/4) 370 g (size 73/4)
Maximum grip force t 90 N 68 N (size 7V4) 98.1 N (at 7.2 V) 55 N to 65 N
81 N (size 7314)
Maximum opening 10.0 cm 7 .6 cm (size 7314) 10.0 cm (size 7314) 7.0cm
width
Average maximum 13.0 emfs 10.0 emfs = 10.7 emfs at 7.2 V 8.75 emfs
speed (size 73/4) (size 73/4)
Operating voltage 6 to 7.2 V 6 to 9 V 6 to 18 V 6V
*Length is measured from thumb tip to proximal base plate of mechanism (at junction of wrist).
tGrip force is measured at fingertips in palmar prehension pattern.
:t:Weight is for mechanism and inner hand shell. no glove.
TABLE 3 Characteristics of Adult Electric-Powered Prehensors: Non- hand-like Devices
NU-VA Synergetic Multicontrol

Device System Electric Greifer Prehensor ETD Powered Gripper
Manufacturer Otto Bock Hosmer-Dorrance Motion Control RSLSteeper
Length* 17.1 cm 19.0cm 16.2 cm = 16cm
Weight t
Maximum grip force
. 540 g
160 N
= 435 g
111 N
408 g
111 N
500 g
50 N
s
Maximum opening 9.5 cm 60° or 10.2 cm§ 78° or 13 cm 8.0cm
width
Average maximum 18.0 cm/s 170°/s or 15.7 cm/sat 6 V 10 cm/s
speed 29.1 emfs 41 .9 cm/sat 14 V
Operating voltage 6 to 7.2 V 9V 6 to 14 V 6V
* Length is measured from the most distal aspect of the prehensor "fingers" to t he proximal base plate of the mechanism
(at j unction of wrist).
t Weight is with Otto Bock-style quick-disconnect w rist. Some prehensors are offered w it h other types of wrist adapters.
:j: Grip force is measured at tips of prehensor "fingers."
§ Angular displacement is a measure of t he arc t raversed by t he fi nger(s). Linear measurement is t he approximate
distance between t he two finge rs at their most distal extent.
mined that 5.1 cm of prehensile experience with prosthetic prehensors Speed of Movement
openi ng was needed most of the time, having an opening of 11.43 cm
but an 8.2-cm opening was needed oc- indicated a preference for the wider Based on a study of users' experiences
casionally. Peizer and associates 1 sug- opening, although it was not used of- with electric prehensors available at
gested the 8.2-cm opening as a mini- ten.2 The maximum openings of the the time, Peizer and associates 1 rec-
mum opening. This recommendation prehensors in Tables 2 and 3 are close ommended a minimum closure rate
was adopted by the Panel on Upper- to or exceed the minimum of 8.2 cm of 8.25 cm/s measured at the finger-
Extremity Prosthetics of the National recommended by Peizer and associ- tip. This minimum standard, consid-
Research Council. Persons who had ates.1 ered a high standard in 1969, is ex-

figure 1 Otto Bock System Electric Hand. The t hree images on the left are w ithout electronics. The fourth image (far right) shows the
on/off switch and control electronics mounted between the finger chassis and t he base plate of the hand. (Courtesy of the Northwest-
ern University Rehabilitation Engineering Research Program.)
ceeded by all of the prehensors in tional physiologic speeds is greatly metic glove. 3 The plastic form fits
Tables 2 and 3. dependent on the control scheme over the mechanism, giving the device
Unpublished data (G. Glickman, with which the prehensor is operated. the general hand-like shape and di-
Northwestern Un iversity, 1978) on For devices capable of higher speeds, mensions. The glove, made of polyvi-
physiologic finger speeds indicate a proportional relationsh ip between nyl chloride, is pulled over the plastic
maximum human finger velocities of the magnitude of the control signal form and provides gender-related
approximately 40 radians/s (2,290°/s) and the response of the prehensor ap- characteristics and cosmetic colora-
for movements th rough a range of pears necessary to achieve confident tion.
75°. Assuming a finger length from and acceptable operation. The mechanism is similar in con-
the metacarpophalangeal joint to the figuration in all models and includes
tip of 10 cm, the maximum velocity at Electric Hand-like Devices the electric motor, an automatic gear
the fmgertip would be 400 cm/s. Otto Bock System transmission, a support structure, and
These data provide an appreciation Electric Hands the finger assembly (Figures 1 and 2) .
for the upper limit on physiologic fin- Otto Bock Health Care manufactures Except in the Transcarpal Hand, the
ger speed, which is far in excess of the several different models of their Sys- electric motor is mounted between
speeds attainable by any of the pros- tem Electric Hands-the Digital Twin the finger assembly and the wrist at a
thetic prehensors. Hand, the DMC (Dynamic Mode right angle to the axes of rotation of
In the same study, finger velocities Control) Plus Hand (see Table 2 for the fingers a nd th umb, in line with
were measured for an untimed pick- specifications), the SensorHand, the the long axis of the forearm . In the
and-place task involving blocks of Transcarpal Hand, and a System Elec- Transcarpal Hand, the motor assem-
various sizes. Average finger velocities tric Hand (with no electronics, for bly is at a right angle with respect to
in th is functional activity were con- use with other manufacturers' elec- the axes of the thumb and fmgers, but
siderably less than the maximwn and tronic controllers). These hands all it is shorter and rotated into the distal
were on the order of 3.0 radians/s have different features but also have palmar region of the hand to shorten
(172°/s) . Only the Hosmer Synergetic several common characteristics. All the length of the hand. In all hands,
Prehensor and the Motion Control System Electric Hands are available in only the thumb, index, and middle
ETD (Table 3) achieve or exceed this the same three adult sizes, denoted by fingers are part of t he mechanism's
speed. The maximmn speeds of elec- the circumferential dimension (in finger assembly. The thumb and fm-
tric hands in Table 2 are less than half inches) at the knuckles- 7 1/.i, 7314, and gers are oriented to provide palmar
the average physiologic finger speed. 8 114. The hands ai·e composed of three prehension. The fiugers, which are
The usefulness of having prosthetic separate parts: the inner mechanism, coupled as one unit, are driven simul-
finger speeds on the order of fwlC- a plastic hand-like form , and a cos- taneously with the thumb in a plane

hr
(for appearance) until the control st:

problem is corrected. t11
The primary prehension pattern of OJ
the System Electric Hand is palmar (i
prehension. The mechanical arrange- fe
ment of the thumb and fingers also ir.
provides cylindrical grasp for objects fE
of moderate dimensions. For very tE
wide objects (near the limit of the tE
hand opening), the fingers are not tl
able to encircle the object to secure it; i<
however, the plastic of the cosmetic e:
glove provides friction that maintains b
a reasonably effective grasp. The use a
of a pliable hand form over the mech- v
anism also improves the grasp be- 0
cause the inner surfaces of the hand
are able to accommodate the shape of s
objects, thus providing many points :a
of contact between the prehension f
surfaces and the object being grasped. t
Several options are available from
Otto Bock to supplement the prehen-
sion features of the System Electric
Hands. A pincers or tweezers that is
keyed to fit the fingers of the hand
Figure 2 Otto Bock SensorHand. The slip sensor is t he small disklike part on the end of
prehensor can provide tip prehension
t he palmar surface of the thumb. (Courtesy of the Northwestern University Rehabilita-
tion Engineering Research Program.) for handling small objects. If the pre-
hensor is equipped with a quick-
disconnect wrist, it can be removed
perpendicular to the axis of the finger linuted by a trade-off between speed and one of a variety of work tools can
joints. The plastic form added over and torque (the higher the speed, the be connected to the wrist of the fore-
the mechanism incorporates the lower the torque). When an object is arm for special functions. These tools
smaller t\-vo fingers. A wire frame gripped tightly, it cannot be released are not electrically powered, however.
within the form links these fingers to immediately because the transmission One could also exchange the hand
the middle finger so that the smaller must reduce the prehension force prehensor for a System Electric Grei-
fingers move somewhat in concert while in low gear until it reaches the fer or other electric prehensor with a
with the mechanized fingers. transition grip force, at which point it compatible wrist connector and elec-
When the fingers are in motion can shift to high gear and open the tronics.
(that is, not gripping an object), the fingers. The delay in opening re- The Digital Twin Hand, the DMC
transmission is in high gear, which sponse is generally not noticeable to Plus Hand, and the SensorHand differ
allows the fingers ai1d thumb to move users if the gripping force is low to primarily in the manner in which the
at a speed up to the maximum noted moderate. hand responds to control signals. The
in Table 2. When an object is grasped, , , Di ital Twin Hand rovides control at
c.....,c....,..r,'---':...a--n-r'-
o-n-'
e-o"T"'-a- v'anety O wor too S can pc-rpcnun
P nl::1,;tir fnrm .._,....,.{ +n ...!!1'o
unu
f+h...., h ;!t..ho.. tJ...o <"nooA
t 1e prc11cns1on iorce
tho ,
reac11es
I iniA1tc: Tl
change ot torque. Wilen a 1
1scr gcner·
10 N, al which point it will ,iutomati- prehcnsion force when the motor is ates a myoelcctrk signal ti
at exceeds
cally down:.hift to drive the ungers off and to prevent the fingers from a m inimum threshold. a c
mtrol sig-
. dose the slower but at higher torque, to a m,LX- opening. It is possible lo override the nal is generated tu open o
,t the am- imum prchensiun force of about 90 effect of the back lock, if necessarr, by prehensor. l·or the lime th
signal is l\. \'\'ithoul this automati..: transmi:s- leYcring the hand lo create verr high plituJe of the myoclectri,
prehensor sion, it would not be possible to forces at the fingertips that exceed the above the threshold, the
,wever. the achieve both the ~peed and maximum torque setting of the hand's slip will continue to operate; h,
xceeds the prehcnsion force of the Otto Flock dutch. Operation of the slip clutch degree to which the signal I
· action of Hand with a 5inglc-motor design. In does not damage the mechanism, and threshold does not alter th
,s of the genera l, :.inglc-motor drive units are the fingers can be closed manually the mechanism. Regardlc
Americ<111 Academy of Orthopaedic Surgeons

Ch~ter 11: Components for Upper Limb Electric-Powered Systems 151
strength of the contraction generating The DMC Plus Hand provides for force component is the tangential
the signal, the prehensor will move at proportional control of the speed of force . This is the force (such as that
only one speed or generate grip force the hand and the force of gripping. produced by gravity) parallel to the
(in low gear) at only one rate. In ef- Contrnl is accomplished with myo- surface of the slip sensor that might
fect, the rnyoelectric signal is activat- electrodes, using a two-site, two- cause an object to slide over the face
ing an electronic switch, and for this f1mction scheme. When the hand is of the sensor, or to slip. For an object
reason, this type of control has been moving in space, the magnitude of not to slip, the ratio of the tangential
termed "myoswitch control." 2 1 An al- the myoelectric signal controls the force to the normal force must be in a
ternative to myoelectric control for speed of the movement. A low ampli- specific range, dependent on the fric-
this hand is the use of electromechan- tude signal (light muscle contraction) tional properties of the surfaces in
ical switches. Otto Bock provides sev- produces slow movement; a higher contact. Whenever the thumb sensor
eral types of switches, including a ca- amplitude signal (moderate to strong detects that the ratio of tangential
ble pull switch, a harness pull switch, muscle contraction) produces faster force to normal force exceeds the al-
and a rocker switch. All switches pro- movement. When gripping, the mag- lowed range, the control electronics
vide operational positions for both nitude of the signal controls the force activate the hand motor to increase
opening and closing the prehensor. applied by the fingers. A low ampli- the grip force until tl1e ratio is
Although the hand moves at con- tude signal will produce a light grip- brought back into the desired range.
stant speed, the user can control the ping force, regardless of how long the A second force transducer, a strain
amount of opening or closing of the signal is maintained. With the Digital gauge in the linkage between the
Twin Hand, a low amplitude myoelec- thumb and fingers, measures the grip
fi ngers by the length of time the con-
tric signal would cause the force to force in situations in which the
trol signal is maintained. To improve
change slowly, but the force would grasped object is positioned in the
control of the opening and closing,
eventually reach the maximum possi- hand in such a way that it is not
the Digital Twin Hand moves at
ble for the hand if the low signal was pressing against the thumb sensor.
11.0 cm/s, slower than the maximum
maintained long enough. Although The strain gauge transducer allows
speed of 13.0 cm/s for the DMC Plus
the user cannot directly feel the force the user to maintain proportional
Hand and the SensorHand. Grip force
being applied to an object, the DMC control of grip force; however, the
is also controlled by the length of
Plus Hand enables the user to gauge hand will not respond automatically
time the control signal is maintained.
the grip force by sensing how hard t he if the held object begins to slip. The
The rate of change of grip force is
controUing muscle is being con- a utomatic response to slip can only be
constant; therefore, the longer the tracted. active when the held object is pressing
person maintains the control signal, The SensorHand (Figure 2) offers against the thumb sensor.
the more the grip force will change. a variety of control modes using one The SensorHand has weight and
When gripping objects, the user can or two myoelectrodes or electrome- maximum speed specifications simi-
grip with a low force by keeping. the chanical switches. The key difference lar to those of the DMC Plus Hand
control signal on for a short period of between the SensorHand and the listed in Table 2. The maximum grip
time. A higher grip force can be other Bock System Electric Hands is force is higher-100 N, compared to
reached by keeping the control signal the ability of the hand to monitor the 90 N for the DMC Plus Hand.
on for a longer period. The maximum slip of a held object and automatically A fourth System Electric Hand
grip force of the Digital Twin Hand is increase the grip force to stop the model is tl1e Transcarpal Hand (Fig-
90 N, the same as that of the DMC slipping. 22 This feature is achieved ure 3), a reworking of the standard
Plus Hand. with a sensor that is built into the pal- configuration of the Bock mechanism
The Digital Twin Hand can be op- mar surface at the end of the thumb to shorten the length of the hand.
erated in a two-site, two-function (Figure 2). The sensor uses a force- This model will fit users with longer
mode with either myoelectrodes or sensitive conductive plastic overlaid residual limbs, such as those with car-
switches, or in a single-site, two- with an array of electrical contacts to pal bones or very short segments of
function mode with a single myoelec- measme the three-dimensional force the metacarpals, and not produce a
trode. In the single-site control mode, applied to the th umb tip when an ob- limb-length discrepancy. 23 The short-
the initial rate of change of the myo- ject is grasped between the thumb ening is achieved by reducing the
electric signal determines if the hand and fingers. The force at the thumb length of the drive unit and rotating it
will open or close. For example, if the has two components. One component into the distal portion of the palmar
user produces a moderate, slowly in- is the normal force, which is the force region of the hand and the proxin1al
creasing contraction, the hand will applied perpendicular to the face of phalanx of the ring finger. With this
close. A stronger, rapidly increasing the slip sensor. This force is approxi- modification, the base of the hand is
contraction will cause the band to mately equal to the grip force pro- essentially the base of the finger chas-
open. duced by the SensorHand. The other sis. Although it is not the shortest
... American Academy of Orthopaedic Surgeons

cumferential djmension at the knuck-

les in inches. The Centri hand design
includes the articulated mechanism
(Figure 4), a hand-shaped inner form
that fits over the mechanism, and a
cosmetic glove that is pulled over the
form.
The Centri Hand mechanism in-
corporates a two-motor design. One
motor drives the fingers open and
shut against a stationary thumb, and a
second motor locks the fingers (to
maintain grip force) when there is no
drive signal. The locking motor is not
powered when the fingers are locked
in place.
The mechanism includes all four
fingers. The first and second fingers
(index and middle) are linked to the
motor drive train and apply the grip
force in opposition to the thumb. The
third and fourth fingers are linked to
Figure 3 The mechanism for t he Otto Bock Transcarpal Hand. Note the different ar-
rangement of the drive unit and position of the base plate compared with the Sensor- the first a11d second so tllat they move
Hand in Figure 2. The loops of wire beneath the base plate secure the mechanism into with the first and second fingers as
the socket lamination. (Courtesy of the Northwestern University Rehabilitation Engi- they open and close. The hand mech-
neering Research Program.) anism is configured to reproduce the
palmar prehension grasp pattern;
electric hand, the Transcarpal Hand is An important feature of the elec- however, the mechanism moves at
3.7 cm shorter than the wrist clisartic- tronics of the Otto Bock System Elec- two axes of rotation. The overall ap-
ulation versions of the other Bock tric Hands is a current cut-off circuit. pearance of the motion of the hand as
System Electric Hands. This circuit senses the motor current it closes on an object is that of a te-
The Transcarpal Hand is also and automatically cuts off power to nodesis type of motion (Figure 5) .
lighter than the DMC Plus Hand by the motor to avoid a stall condition. The base of the hand extends with re-
about 120 g. The size 7 1/ 4 Transcarpal Stall occurs when the drive unit has spect to the forearm as the fingers
Hand weighs only 320 g. Other than reached its maximum output torque close, and it tlexes as the fingers open.
the length and weight, the Transcarpal and the motor stops rotating. Power- This pattern of hand motion may give
Hand has performance specifications ing a stalled motor draws high cur- the hand a more physiologic appear-
similar to those of the DMC Plus rent that will quickly deplete the bat- ance. The biaxial motion pattern is
Hand (Table 2). It has the same aver- tery capacity. All System Electric unique to the Centri Electric Hands.
age maximum speed and the same Hand models have a current cut-off The Centri Electric Hands are par-
maximum grip force. The Transcarpal circuit except the model designed to ticularly notable because they are the
Hand is available with DMC Plus be used with controllers from other lightest and shortest electric hands
control or Digital Twin control. manufacturers, which has no elec- (Table 2) . The size 7% Centri Electric
The fifth System Electric Hand tronics. When using this model, exist- Hand is about 2.5 cm shorter than the
model is a version with no electron- ence of a current cut-off feature Bock Transcarpal Hand and weighs
ics; it can be used with electronic con- (sometimes referred to as an energy- 250 g versus 320 g for the size 7 1/ 4
trollers from other manufacturers. saving feature) in the controller Bock Transcarpal Hand. The maxi-
The electrical connection to this hand should be determined because the mum grip force, maxinmm opening
is directly to the motor leads through presence or absence of this feature width, and average maximum speed
tl1e on/off switch. Performance char- will affect overall performance. of the Centri Electric Hands are lower
acteristics will depend on the particu- than the Otto Bock DMC Plus Hand
lar electronics driving the hand and Centri Electric Hands (Table 2).
the voltage of the battery. The other The Centri Electric Hands are avail- The Centri electronic hand con-
System Electric Hands are designed able in two adult sizes, 7 V4 and 7%. As troller is a separate unit not built into
for a 6.0-V nickel-cadmium or 7.2-V with all hands described in this sec- the hand. This factor should be con-
lithium ion battery. tion, these sizes approximate the cir- sidered in the design of any prosthesis

Figure 4 Centri Electric Hand. All four f ingers are incorporated into the mechanism. (Courtesy of the Northwestern University Reha-
bilitation Engineering Research Program.)
incorporating the Centri Electric

Hand. It can be operated with myo-
electrodes or Force Sensing Resistors
and provides proportional control of
speed and rate of change of grip force.
M otion Control Hands

Motion Control produces only adult-
sized electric hands in sizes 7 1/4, 7 %,
and 8 114. The hands are available in
four versions-standard, short, with a
flexion wrist, and with a built-in con-
troller. Table 2 lists the features of the
standard version. Like the Otto Bock
and Centri hands, the Motion Con-
trol Hands are made up of three
parts: the mechan ism, a hand-shaped
inner form that fits over the mecha-
nism, and the outer cosmetic glove
(Figure 6).
The mechanism of the Motion
Control Hand has a transverse-
mow1ted motor and automatic gear Figure 5 The Centri Electric Hand has two axes of motion during opening and closing.
transmission driving the thumb and As the fingers close, the base of the mechanism extends with respect to the forea rm. As
first tw'o fingers (index and middle) t he fingers open, the base f lexes. The pattern of hand motion, similar to a tenodesis
type of gripping motion, is believed by some users to give the hand a more physiologic
in opposition. The tw'o fingers are
appearance. (Courtesy of the Northwestern University Rehabilitation Engineering Re-
g linked together to move as a single search Program.)
j unit, and both the fingers and the
r thumb move as the hand opens and
:l closes. The on/off switch, mounted from the gear train and can be fast speed in high gear, when the fm-
below the finger assembly, incorpo- opened manually with little force. gers are moving freely, and high
rates a third position that acts as a This is the only electric hand that of- torque in low gear, when the fingers
0 safety release. When the switch is fers this feature. are closed on an object. The Motion
pushed all the way in from the back of The automatic transmission pro- Control Hand has the highest pre-
is the hand, the fingers are disengaged vides the Motion Control Hand with hension force of the four hands listed
b
-
flexion mechanism is built into the
hand between the drive assembly and
the WTist connector, adding slightly
more than 0.3 cm to the lengtl1 of the
size 7% hand and increasing the
weigh t by 48 g over that of the stan-
dard size 7% hand. With the flexion
in three positions: 30° of flexion, neu-

tral, and 30° of extension. The lock is
released manna.Uy by a spring-loaded
push plate on the back of the hand
n~di trt~ ~ll u 111
hand with flexion wrist option have
the same specifications for maximum
grip force, maximum opening width,
and average maximum speed, as
1 Control Electric Hand. Shown from left to right are the mechanism, shown in Table 2 for tlle standard Figure 6 Motio
1JiVU d lc\l l,JlUUdt' Ji ~ ~ nri f'\r"f'l~ttf'\f1:.~11 r un ~t1f'\n ·n ,:>rrr\ltC- -th P ,.."".he hn."'U....-hr-r..s
IICHVI,\'+) fJdlftldf I) IVI IYU), dlt dLL.,»ory ulna. •s
ot the Motion E The CO• c.tjnp /'l@f,d))'T,jf.tt,ljft~nfifr\Pe1111y /'ld!:c'dft/1 nuyrc1/f/.J nrnn;atnr
1 he
tourth version
ProControl 2 s Control Hand has th(
mill into the electronic controller
· ProHand, re- hand. This version, th
of battery and quires only connection
rist connector. myoelectrodes at the v
lviV;l.!,l_'lf,11('., ';\,~~~.. ,v .. , ,-rp111dl01 . I lie OICeps IS ~ v -·,r:<o11,p.,,,.~~!IJ-- - - - ~ - - ThP Pm.<'."J1D.!mL?, .<'.l<=,
h the elbOW flp)(p(] goo 0( WhPn ~l'IPPrl nf nnwPr 1< r<>n11ir<>rl Ifunctionina best wi
like shape and appearance. 11 For the

----- _... ,,. ~
most part, the nonhand
:u.n. •'-') ....-i.YJ. \...Ql }'l.
\;.U~
prehensors
1,- --
\.,A:C"-.lJ.,)QJ. --'
uscd"'i"1- spcciar~1fua'tioristo'con; -
TJ...,.. •. -!,..,. '1"""•• ...,.,.,.... ............ •J.... ~ ti .
c a
ement the function provided by p
edric. hands. l lowcver, some indi- e
Juals, particularly those wilh bilat- v
al amputations,
.._ '
might
'"'-
choose
t
to useU\,; • l
' <;,
...
Figure 9 Otto Bock System Electric Greifer. The right panel shows the Greifer with the fingers fully opened. The center view shows the
wheel that rotates as the f ingers move; t his wheel can be turned to open or close the fingers manually. The lever just above the wheel
disengages the fingers from the gear train, allowing them to be opened freely. (Courtesy of the Northwestern University Rehabilita-
tion Engineering Research Program.)
chined for specific applications. A ables users to grasp lighter and more Hand, the Greifer also has built-in
screwdriver is required to adjust the delicate objects at the lower force and wrist flexion. The plane of flexion is
position of the tips or to interchange stop the closing signal before higher perpendicular to the prehension sur-
them. forces are applied. The transmission faces of the fingers.
In comparison to the System Elec- of the Greifer differs from that of the Otto Bock control options for the
tric Hand, the Greifer is longer by System Electric Hand in that there is Greifer include the DMC Plus and the
3 cm and is about 100 g heavier, mak- very little delay between an "open" Digital Twin options. These control-
. . . .
. The center image shows the safety re lease lever that disengages the fingers from the gear train. The Figure 11 Motion Control ETC
1oving fi nger in its fully opened position; t he other finger is stationary. (Courtesy of the Northwestern view on the right shows the n
eering Research Program.) University Rehabilitation Engif
1e almost only one of the two hook-shaped fin- locked positions-30° of flexion, two factors contribute to t
he Syner- gers of the ETD is driven; the other is neutral, and 30° of extension . All instantaneous response of
ty to have stationary. As with the Motion Con- versions of the ETD include an energetic Prehensor and the abil
nal levels. trol Hand, the ETD incorporates a gy-saver circuit to prevent the motor good control even at low sif
safety release that disengages the from being powered in a stalled con-
moving finger from the gear Lrai n. dition. Motion Control ETD
nsion de- The ETD is available in left and right The newest nonhand prehc
I Electric models because of the moving and RSLSteeper MultiControl vice is the Motion Contr<
hich was stationary finger arrangement. Powered Gripper Terminal Device (ETD), -..
: 11). The The ETD is the lightest nonhand The current MultiControl Powered released in mid 2003 (Figur
; a motor prehension device and offers the wid- Gripper from RSLSteeper (Figure l2) mechanism of the ETD use
ar to that est maximum opening width of any is essentially a complete reworking of and gear transmission simi
and. The electric-powered prehensor. It can be the original Powered Gripper de- of the Motion Control 1~
a water- operated at voltages from 6 to 14 V. scribed by Kemp. 11 Except for the mechanism is encased I
tbe user Above lO V, the speed of the ETD ex- angular hook-shaped fingers, little resistant housings, allowin1
and non- ceeds that of the Hosmer Synergetic remains of the early version. The de- to expose the ETD to water
damaging Prebensor. vice now has a single motor drive unit corrosive liquids without
s are the The ETD is available in three ver- that powers both fingers to open and the mechanism. The 6nge
-powered sions: standard, with flexion wrist, close simultaneously. The MultiCon- same as those of the bod,
look and and with the built-in ProHand elec- trol Powered Gripper has the lowest APRL Voluntary Closing l
·rehensor; tronic controller. The standard ver- maximum grip force, the smallest the Hosmer Synergetic l
advanta- sion requires an external controller, maximum opening width, and the therefore, it offers the sami
ts-active such as Motion Control's ProControl slowest average maximum speed of geous prehension patter:
active cy- 2. The flex.ion wrist option increases any of the nonhand prehension de- lateral and tip prehension,
,f moder- the length beyond that of the stan- vices (Table 3). lindrical grasp for objects 4
LOOk pre- dard version. As with Lhe Motion The body and fingers of the Pow- ate diameter, and passive I
;ers and Control Hand, the flex.ion wrist op- ered Gripper are metal castings. The hension. Unlike the fin
:ol Hand, tion for the ETD provides three fingers are contoured to provide pas- thumb of the Motion Cont
aedic S11rgeons American Academy of OrthoJ

••
Figure 12 RSLSteeper MultiControl Powered Gripper. A, Fingers in fu lly opened position. B, Grooved lining on the prehension surface
of the fingers. C, External wheel that can be turned manually to open or close the fingers when the Powered Gripper is not respond-
ing. (Courtesy of the Northwestern University Rehabilitation Engineering Research Program.)
sive hook prehension and have flat-

tened opposing surfaces for powered
lateral and tip prehension. The open- •
ing between the fingers is also con-
toured to accommodate cylindrical
objects. The prehension force of the
Powered Gripper is enhanced by the
use of relatively soft frictional rubber
pads to line the fingers. The pads are
L grooved over their surfaces. The
)
grooves allow the pads to deform and
f
mold to the shapes of held objects,
distributing the prehension force over
a broader contact area.
An external wheel on one side of
t
the MultiControl Powered Gripper is
i connected to the drive train of the Figure 13 Hosmer NY Prehension Actuator. The complete forearm assembly is shown at-
fingers. If the device fails to open, the tached to the Hosmer NY Electric Elbow. The mechanism of the Prehension Actuator
user can tum the wheel to open the (with the forearm shell removed) and the forearm saddle assembly with forearm rota-
t
tion joint are shown next to the completed assembly. (Courtesy of the Northwestern
t fingers manually. University Rehabilitation Engineering Research Program.)
e The same control schemes used for
f the RSLSteeper MultiControl Plus
Electric Hand are available with the Hosmer NY Prehension Table 3. The PA is a forearm assembly
Powered Gripper. A special version of Actuator (Figure 13) containing a motorized
the Powered Gripper without elec- Because the NY Prehension Actuator winch that provides electric-powered
e tronics is available for use with other (PA) is not a true prehension device, operation of a cable-actuated, volun-
manufacturers' controllers. its characteristics are not .included in tary-opening split hook. 27 The device

b
•
was origina!Jy designed by William Commentary on Electric With the exception of ilie Otto
Lembeck of New York University as a Prehensors Bock Electric Wrist Ro tator, all com-
complete forearm setup for use with mercial prostl1etic wrist components
the Hosmer E-200 a11d E-400 me- The interplay of psychological and so-
are manually positioned or body
chanical elbows or the Hosmer NY cial aspects associated with the shape
powered. Many factors complicate tl1e
Electric Elbows. In that configuration, of the human hand and the need for
development of electric-powered
the mechru1ism occupies the distal prehension ftmction and independent wrist components. From a compo-
10.8 cm of the forearm with a rota- capability are complex. Generaliza- nent design vie,vpoint, size and
tion joint proximal to the mechanism. tions favoring one type of prehensor weight constraints are imposed by the
The forearm segment proximal to the over any other are limiting, and there location of the joint. The device must
rotation joint contains the forearm is little consensus among users of fit witl1in a cylinder about 5 cm in di-
saddle assembly for the elbow and, prosthetic prehensors as to which de- ameter and occupy as little length as
because of the saddle's d imensions, vice is best su ited as a replacement for possible, to accommodate a variety of
has a minimum length from the el- the physiologic hand. Even the simi- residual limb lengths.
bow axis of 9.5 cm. The complete larity to the anatomic hand tl1at is The component must also be rela-
forearm setup has a minimum length possible with modern electric hand- tively lightweight to min imize coun-
from the elbow axis to the distal face like prehensors is not universally de- terforces exerted on the residual limb
of the wrist of 20.3 cm. Longer fore- sired. Some individuals, particularly (for a transradial fitting) and mini-
arms are provided by lengthening the those with b ilateral amputations, are mize countertorque, which would re-
distal forearm segment, thus keeping appreciative of the prehension and duce the lift capacity of a prosthetic
the weight of the mechanism (about performance advantages of prehen- elbow u1 higher level fittings . And
218 g) as proximal as possible. Rota- sors that do not have a hand-like though lightweight, the structure
tion to orient the split hook is done shape. Others find the apparent cos- must be robust enough to withstand
proximal to the PA to maintain an mesis of electric hands insufficient the forces that are exerted on the pre-
efficient alignment between the cable ru1d are repelled by it, preferring a de- hensor and transferred back to the re-
attachment post of the split hook and vice that has a form truer to its grip- sidual lun b through the wrist joint.
the cable leading from the actuator ping function. Until a more versatile Another consideration with respect to
mechanism. weight is th e requirement for rela-
anth ropomorphic prehension device
The PA is typically powered by a tively low power consumption to
is developed, the need for a variety of
6-V battery pack, and at that voltage eliminate the need for a11 additional
options will remain.
it can open a split hook with three battery if used in conjunction with
rubber bands. The time required to oilier electric componen ts.
open the hook to its limit is approxi- Wrist Mechanisms The key functional question is
mately 1 second, though it is depen- which joint motions should be pro-
Studies of hand use in performing
dent on the number of bwds used vided. The anatomic forearm and
vru·ious common activities and occu-
with the hook. wrist jou1ts can be approximated by a
pational tasks have shown that fore-
Controlled activation of the PA triaxial joint with tl1e axes of rotation,
arm rotation and wrist motions are
causes it to pull the split hook open. If flexion, and deviation (roll, pitch, and
used to a significant extent in these
the control signal stops before the PA 17,28-3 1 yaw) havu1g a point of intersection
...,--~,-yn.~n o~S"'".1._,..i...""'"'"-1:.-L.1,~~..:....~...i....~--'~i#,l.~~~-.I.:~
Chapter 11: Componen ts for Upper Limb Electric-Powered Systems 161
Figure 15 Wrist f lexion option for the Motion Control Electric Hand. Pictured from left
t o right are 30° of extension, neutral position, and 30° of flexion. The plate extending
from the left at t he base of t he hand is t he spring-loaded lock release. (Courtesy of the
Northwestern University Rehabilitation Engineering Research Program.)
methods for actuating and position- the lamination collar to the proximal
ing mechanical wrist components surface of the motor housing.
that do not necessarily require the The rotator is relatively lightweight
contralateral limb. However, these at 96 g, approximately 20% of the
Figure 14 Otto Bock Electric Wrist Rota· components normally cannot be op- weight of an Otto Bock System Elec-
tor. The rot at or (shown below by itself ) erated to perform work, such as turn- tric Hand. It is also relatively energy
interfaces mechanically and electrically ing a handle. Nor can they typically efficient, drawing a no-load current
with the Otto Bock-style quick· of 150 mA; the stall current is 1,000
disconnect w ri st adaptor. (Courtesy of the
be adjusted dynamically during a mo-
tion, such as adjusting the wrist atti- mA. The power requirements are such
Northwestern University Rehabilitation
Engineering Research Program.) tude while raising a utensil to the that it is feasible to operate an Otto
mouth. Although these deficiencies Bock System Electric Hand or Greifer
have inspired many designers to at- along with the Electric Wrist Rotator
limb, which can be used preferentially from a single 6- or 7.2-V Otto Bock
tempt to fashion a more versatile
for activities involving significant battery. \Nhether one battery will last
electric-powered wrist, advances have
forearm and wrist motion. On tl1e an entire day depends on the extent to
been slow and no multiaxial compo-
prosthetic side, the person could use which the devices are used.
nents are commercially available.
compensatory motions of proximal The rotator mechanism is also pro-
l
physiologic joints and have manually Otto Bock Electric Wrist tected from external forces through
l positioned mechanical wrist compo- its attachment to the wrist lamination
Rotator
) nents that would offer adjustable collar. Side forces and axial forces ex-
fixed orien tations of the prehen sor. The Electric Wrist Rotator developed erted on the prebensor are transferred
Altllough operation of these compo- by Otto Bock addresses many of the to the lamination collar and pros-
,1
nents typically involves the physio- difficulties outli ned in the preceding thetic forearm rather than to the rota-
tl
logic hand, the operation is relatively paragraphs to provide the functional tor m echanism. Excessive torque on
s
quick and straightforward. The fact analog of forearm rotation (Figure the prehensor will cause the ratchet of
il that tllis technique is so widespread 14). The drive unit is a single motor the prehensor's portion of the qu.ick-
0 underscores t he remarkable qualities and gear reducer with a rotation axis disconnect wrist to slip rather than
11 of the physiologic wrist. Persons us- in line with the longitudinal axis of the backdrive the wrist mechanism.
ing tllis technique do so without giv- forearm. The rotator is structurally The coaxial electrical co upling of
1e ing much thought to what they are supported within the lamination col- the Bock quick-disconnect wrist al-
:o doing with their intact wrist and band lar of the Bock quick-disconnect wrist lows the rotator to turn an electric
t- while using them to position the and can fit any of the three sizes of prehensor continuously in either di-
1- prosthetic wrist. wrist lamination collars, which have rection. In general, however, the per-
il, For individuals with bilateral arm diameters of 4.0, 4.5, and 5.0 cm. Its formance characteristics of the rota-
ct amputations, there are alternative lengtll is 6.7 cm from the distal edge of tor have been compromised to

p
tor are available from Hosmer Dor-

rance and Liberating Technologies.
Specifics on the control options and
requirements can be obtained from
the manufacturers. Contact informa-
tion for all the manufacturers men-
tioned in this chapter is provided in
Table 1.
Wrist Flexion Units

Although no commercial components
provide electric-powered wrist flex-
ion, this is an important function for
individuals with bilateral arm ampu-
tations and for some with w1ilateral
amputations. Accordingly, it is useful
to know how this function can be
provided in prosthetic fittings involv-
ing electric prehensors.
The Otto Bock System Electric
Greifer and the Motion Control Elec-
tric Hand and ETD have wrist Aexion
options built into the prehensors. The
flexion joint for the Otto Bock System
Electric Greifer is a manually
p
TABLE 4 Characteristics of Adult Electric Elbows
NY Electric Elbow Utah Arm 2

Device (large model) Boston Digital Arm System (elbow only)
Manufacturer Hosmer Dorrance Liberating Technologies Motion Control
Turntable diameter 7.1 cm 7.0cm 7.0cm
Humeral dimension* 10.8 cm 10.5 cm 13.0 cm
M inimum forearm No required forearm 20.3 cm 24.8 cm
dimensiont componentry
Weight 0.55 to 0.62 kg 1.02 kg 0.91 kg
(depending on battery used (with standard forearm shell) (with standard length
and without forearm) forearm shell)
Maximum live-lift capacity 3.4N·m ,. 14.2 N·m 4.3 N·m (estimated)
Passive (locked) lift capacity 24.4 to 27.1 N·m 68 N·m 68N·m
Range of motion 5° to 135° 0° to 135° 15° to 150°
Speed 100°/s, no I oad 123°/s, no load 112.5°/s, with weight of
56.5 °/s, with countertorque 113°/s, with countertorque Otto Bock System Electric Hand
of 1.7 N·m of 1.6 N·m countertorque ,. 1.44 N·m
Battery type* 5 or 6.25 V; 12 V; removable, but remains in 12 V; removab le
(all rechargeable) non removable arm during recharging
*With the elbow flexed 90°, the humeral dimension is from the proximal edge of the turntable lamination collar to the distal aspect of
the elbow cap.
tFor both the Boston Digital Arm System and the Utah Arm 2, length is measured from the posterior aspect of the elbow, flexed 90°,
to the most distal aspect of an Otto Bock quick-disconnect wrist lamination collar.
*Nonremovable and removable refer to the procedure used for recharging.
locked to locked. It can be actuated bow, the Liberating Technologies Bos- tivity. However, lifting capacity is an
with a switch or with a two-site, two- ton Digital Arm System, and the Mo- important characteristic, especially
function myoelectrode setup using tion Control Utah Arm 2. These for individuals with bilateral amputa-
cocontraction of the muscle sites. A elbows differ from one another in tions. The three elbows have maxi-
mechanical override allows for opera- mechanical configuration, drive mum live-lift (lifting by powering
tion of the lock if the battery is de- mechanism, and control options. Ta- the elbow) capacities ranging from
pleted or an electronic problem oc- ble 4 summarizes characteristics of 3.4 N·m to 14.2 N·m (Table 4). At a
curs. these devices, and each of the elbows distance of 30 cm from the elbow
is described below. axis, the Hosmer NY Electric Elbow
RSLSteeper Electric Elbow In adclition to the powered elbow can lift a maximum weight of 1.1 kg;
Lock joint, all of the elbows incorporate a
the Boston Digital Arm System can
friction joint or turntable for manual
The RSLSteeper Electric Elbow Lock lift a maximum weight of 4.7 kg. The
humeral rotation. With the Hosmer
(Figure 17) was the first to be incor- weight of the materials of the fore-
NY Electric Elbow, the friction is ad-
porated into a body-powered elbow. arm, wrist component, and prehen-
justed by a crown nut on a threaded
The electric lock is a major advantage sioo device must be subtracted from
stud centered in the proximal surface
for inclividuals who can benefit from these values to estimate the maximum
of the elbow enclosure. Access to this
a cable-actuated mechanical elbow nut must be provided in the fabrica- weight of an object that can be held
but have difficulty producing the con- tion of the humeral shell. The Boston and lifted. An adult electric hand-like
trol motions or forces required by the Digital Arm System uses a split com- prehensor weighs roughly 0.45 kg.
body-powered lock. The lock motor is pression ring, and the Utah Arm 2 has Asswning a distance of 30 cm from
operated by an electromechanical an external split co!Jar for friction ad- elbow axis to palm, this type of pre-
switch or by single-site myoswitch justment of the humeral rotation hensor would reduce the maximum
control. There is no mechanical over- joint. No special accommodation weight of an object that can be lifted
ride in the RSLSteeper unit. must be made in the fabrication of to approximately 0.65 kg for the
the humeral shell for these two el- Hosmer NY Electric Elbow and 4.25
bows for access to the adjustment. kg for the Boston Digital Arm System.
Elbow Mechanisms
Elbows are generally used to posi- Subtracting the weight of the forearm
Three electric elbows are available for tion the prehension device, then kept and wrist componentry would further
adults: the Hosmer NY Electric El- in place while performing some ac- reduce these values.

ln comparison, the lifting capacity

of the physiologic elbow can exceed
25 kg for an adult man at low speeds
of Aexion 33 and can exceed 13 kg at
flex:ion speeds of about 57°/s.34
Clearly, the same types of activities
cannot be performed with an electric
elbow as with the physiologic elbow,
particularly those involving the active
lifting of moderate to heavy loads.
Heavier loads can be lifted by a
prosthesis with an electric elbow, but
in a passive manner-by locking the
elbow in place after prepositioning it,
using body movement and posture to
orient the prehensor to grasp the ob-
ject, and then straightening the body
without actively moving the elbow Figure 18 Hosmer NY Electric Elbows. The exoskeletal model in the foreground has a
humeral turntable and a forearm saddle for lamination. The endoskeletal model on t he
joint. In this way, objects that exceed
right has attachments for humeral and forearm pylons. The cables coming from the tops
the live-lift capacity of the elbow can of both models are connections for the controller and battery pack.
still be lifted. However, even this tech-
nique is limited by the breakaway de-
vice or slip clutches incorporated into speeds of adult electric elbows (Table position. Accordingly, as electric el-
the elbow mechanisms to protect 4) are far less than these values. How- bows have become faster, the use of
them against mechanical overload. ever, maximum speeds of elbow flex- proportional velocity control has
This overload protection also serves ion are probably rarely attained in grown. In this type of control, the
to protect the user, to a degree, from daily functional activities. Peak physi- magnitude of the input signal, which
excessive forces transferred through ologic elbow speeds more typical of the user is presumed to be able to reg-
the socket during accidents such as those that might be seen in common ulate, determines in direct proportion
falls. The elbow would give way if the functional activities have been found the speed of motion. By creating a
person fe]J onto the prosthesis. Both to be correlated to the amplitude of higher amplitude signal, the user di-
the Boston Digital Arm System and the movement with the following ap- rects the elbow to move faster, up to
the Utah Arm 2 have passive lift ca- proxin1ate relationship: speed (0 /s) = the limits of the mechanism; by pro-
pacities of 68 N·m, and the Hosmer (2.9°/s/0 ) x (angular distance in °).32 ducing lower level signals, the user
NY Electric Elbow bas a capacity be- For a movement over a 10° range, the drives the elbow at slower speed.
tween 24.4 N·m and 27.l N·m. With peak velocity during the movement
an electric prehensor and distance to would be about 29°/s. For a greater Hosmer NY Electric Elbow
the elbow axis of 30 cm, the Boston angular movement of 90°, the peak The Hosmer NY Electric Elbow was
Digital Ann System and Utah Arm 2 velocity would be about 261°/s. designed at New York University by
can be used to passively lift an object Therefore, it would appear that all of William Lembeck under the direction
weighing up to 23 kg; the Hosmer NY the electric elbows can approach of Sidney Fishman.27 The prototype
Electric Elbow will passively lift 8.1 to functional physiologic speeds over of this mechanism was originally con-
9.1 kg. short distance movements but are sig- ceived for use by children and was
As with lift capacity, the speed of nificantly slower than the physiologic evaluated in the 1970s: Subsequent
elbow motion is often cited as a sig- elbow over larger angular movements. modification of the prototype design
nificant feature in comparisons of Perhaps more important than the and the involvement of the Hosmer
l prostl1etic elbows. However, impor- measured speed of an electric elbow is Dorrance Corporation led to the
tant perspective can be gained by con- how it is controlled in relation to its commercialization of large- and
l sidering speeds of electric elbows in speed of response. For an extreme ex- medium-sized versions, introduced in
i comparison to physiologic perfor- ample, it would be difficult to posi- 1983. The two sizes are equivalent to
e mance. The average maximum speed tion a fast elbow using switch control the E-400 and E-200 Hosmer Dor-
5 of physiologic elbow flexion for adult that actuated the elbow at full speed rance body-powered elbows, wh ich
l. men has been measmed at about in flex:ion and in extension. The user can be alternatively fit to prostheses
n 600°/s for movements through a 120° would have a tendency to overshoot originally configmed with the electric
:r range, 32 with peak speeds in excess of the target position and would likely elbow. Hosmer Dorrance also intro-
900°/s.32•35 Clearly, the maximum not be able to make small changes in duced versions of the elbows for exo-

b
-
trol using two-function electrome-
chanical switches; and two-site, two-
function myoswitch control. A variety
of electromechanical switches are
available from the manufactmer, in-
cluding cable and harness pull
switches and one-site and two-site
push switches. Other switch configu-
rations are also possible. Both the
switch control and the myoswitch
con trol operate the elbow at one
speed. This speed cannot be adj usted
and is determined by the battery volt-
age, the load on the elbow, and the di-
rection of movement (the elbow is
faster extending with gravity than lift-
ing against gravity). The elbow can be
used with controllers from other
manufacturers, such as the VariGrip
Controller from Liberating Technolo-
gies. This controller provides propor-
tional control of the elbow and allows
for a greater variety of input trans-
ducers.
Numerous configurations are pos-
sible using the electric elbow in con-
Figure 19 Liberating Technologies Boston Digital Arm System. Shown above is t he com- junction with wrist and prehension
plete elbow-forearm assembly. The lower photograph shows t he forea rm support frame components that have control sources
and the programmable controller circuit board after the 12-V battery pack (bottom left) separate from the source (or sources)
and forearm shell are removed. (Courtesy of the Northwestern University Rehabilitation operating the elbow. Hosmer Dor-
Engineering Research Program.)
rance does not offer methods for inte-
grating control of the elbow with
skeletal and endoskeletal applications reduce the functional lift capacity, the other electric components, except its
(Figure 18). maximum weight of an object that Hosmer NY PA. In configuration with
The same motor and drive mecha- can be lifted by the elbow. the PA (Figure 13), the elbow can be
nism, which is contained in the elbow A pawl-type locking mechanism, operated by a three-function cable
cap, is used for all versions of the el - placed in an early stage of the drive pull switch. The first two functions
bow; therefore, mechanical perfor- train, locks the elbow virtually any- operate the elbow in flexion and ex-
mance characteristics are the same for where through its 130° range. Locking tension, and the third function (with
all models. External dimensions, the is automatic whenever the control the switch control cable fully ex-
turntable, and the forearm saddle at- signal ceases. The elbow can also be tended) operates the opening of the
tachments vary by model. The ab- made to swing freely by driving it to PA. The relatively light weight of the
sence of fixed componentry in the its fully extended position, at which PA in combination with an aluminum
forearm and the use of a forearm sad- point the free swing automatically en- split book (compared with the weight
dle provide considerable freedom in gages. Once engaged, the elbow can of electric-powered prehensors in Ta-
the length and customized shaping of be swung or pushed unpowered any- bles 2 and 3) and the more proximal
the forearm section. where within its full range of motion. location of its center of mass help
The elbow is powered by a separate Free swing is disengaged by activation maximize the effective lift capacity of
battery pack, available in four and five of the flex.ion control. Elbows can be the NY Electric Elbow.
AA-cell configurations, which can be equipped with or without the free
positioned within the prosthesis as swiug feature, and elbows without Liberating Technologies
appropriate. Placement in the hu- free swing can be retrofit to incorpo- Boston Digital Arm System
meral section is preferable to place- rate it. The Boston Digital Arm System (Fig-
ment in the forearm because addi- Two control options are available ure 19) is the third commercial model
tional weight in the forearm will from Hosmer Dorrance: switch con- of the device originally known as the

Boston Elbow. The origins of this el- A bidirectional, reverse locking hook prehensor.38 In 1982, Motion
bow date back to the 1960s in a coop- clutch holds the position of the elbow Control, Inc, the company formed to
erative research and development whenever it is unpowered. The elbow manufacture and market the Utah
venture of tl1e Liberty Mutual Insur- can be locked in any position within Arm, introduced a proportional myo-
ance Company, the Liberty Mutual its range of 135°. A free swing range electric controller that allowed the el-
Research Center, the Massachusetts of 45° of flexion from the stopped po- bow to be used in conjunction with
Institute of Technology, the Harvard sition of the elbow can be engaged an electric prehensor. 39•40 An addi-
University Medical School, and Mas- and disengaged by manual operation tional control option, the force-
sachusetts General Hospital.36•37 The of a mechanical slide bar. actuated ServoPro, was introduced
first prototypes were encouraging, but Of the three adult electric elbows, in the 1990s. During that decade,
considerable development by the Lib- the Boston Digital Arm System offers the electronics for the elbow and
erty Mutual Research Center during the greatest range of control options, hand underwent major revision; the
the first half of the 1970s was neces- including multicomponent control, Utah Arm 2 was introduced in 1998
sary to produce a version that could through the programmability of its (Figure 20).
be commercialized. Robert Jerard re- controller. The system· can accept in- As it is presently configured, the
designed the original prototype, prov- puts from myoelectrodes, force- Utah Arm 2 includes a motorized el-
ing that a commercial version was sensitive resistors, linear resistors, and bow mechanism, a friction-type hu-
feasible, and T. Walley Williams III switches. Depending on the number meral turntable, a forearm shell, and
implemented the commercialization of physiologic control sources avaiJ- electronics for both the elbow and an
and directed subsequent design alter- able from the user, the system can be optional electric prehension device.
ations. Trials with the commercial el- configured to control the elbow, an The prehensor control electronics can
bow were begun in 1975, and the first electric prehension device, an electric also operate a wrist rotator alternately
Boston Elbows were made available in wrist rotator, and two other electric with the prehensor.
1979. Since its introduction, the el- components. Although it is p'referable The Utah Arm 2 is available in one
bow system has undergone two major to use separate and independent con- size. The battery pack and elbow elec-
redesigns. In its present form as t he trol sources for each component, se- tronics are contained within the sta-
Boston Digital Arm System, the sys- quential control can be used when tionary (with respect to the humeral
tem integrates a high-performance there are fewer control sources avail- section) enclosure distal to the turn-
direct-drive electric elbow with a able to the user than components to table. The motor, mechanical trans-
microprocessor-based controller ca- be controlled. Proportional control mission, and prehensor electronics
pable of accepting a variety of input schemes are preferable to take full ad- are located in the forearm section.
transducers and controlling up to five vantage of the Boston Digital Arm The forearm shell is a finished
devices. System's electric elbow and high- injection-molded plastic enclosure
The electric elbow portion of the performance prehension devices. that can be cut to a shorter length or
Boston Digital Arm System is avail- However, when switch control is nec- lengthened by addition of an exten-
able in one size and is configured with essary, the Boston Digital Arm System sion. Elbow rotation occurs about an
tl1e motor and gearing within the el- can be programmed to limit the per- axis through the anterior aspect of the
bow cap and the battery and electron- formance of devices to enable effec- joint. This placement allows flexion to
ics supported in a metal forearm tive control by switches. approximately 150°, bringing the pre-
frame. A prefabricated plastic forearm Control schemes for the Boston hensor nearer to the face with less
shell encloses and protects the fore- Digital Arm System continue to shoulder flexion than is possible with
arm componentry and provides ithe evolve in response to clinical fittings. other elbow designs. Modularity of
wrist connection. Specific information on available the electrical and mechanical assem-
The drive mechanism includes a control options is available from the blies is a hallmark of the Utah Arm 2,
t
tluee-phase brnshless motor with manufacturer (Table 1). facilitating access for troubleshooting
direct-drive gearing and a wave gen- and replacement of subtmits.
l erator to achieve efficient gear reduc- Motion Control Utah Arm 2 Two control options are available.
)
tion. Although a three-phase brush- The original Utah Artificial Arm was The first is a two-site proportional
f less motor requires additional control developed at the University of Utah in myoelectr ic control. Switch control is
electronics, this type of motor offers the latter half of the 1970s by a team not feasible because of the relatively
higher overall performance (Table 4) . led by Stephen Jacobsen, PhD. In its high speed of the elbow, which is
The maximum live-lift capacity of the first clinical fitting in 1980, the system faster than 100°/s with an electric pre-
Boston Digital Arm System is more included tl1e electric elbow mecha- hension device (Table 4). Nonlinear
than three times that of the Utah Arm nism and the control electronics de- filtering of the myoelectric signals
:1 2 with comparable average maximlU11 veloped by the Utah team and a body- provides for quick response of the el-
e speed characteristics. powered voluntary-opening split- bow to sudden high-amplitude

b
•
ducer fastened in line with a user's

control harness. Pulling on the har-
ness with forward flexion of the arm
at the shoulder, in the case of a trans-
humeral fitting, or scapular abduc-
tion for a shoulder disarticulation fit-
ting exerts a force on the transducer
that is converted to a control signal.
When in elbow control, the magni-
tude of the force on the transducer
directly controls the angular position
of the elbow. As with myoelectric
control, the elbow is locked by hold-
ing it stationary for a short period of
time. When locked, force on the
transducer controls opening and dos-
ing of an electric prehensor. Unlock-
ing and return to elbow control is ef-
fected by a quick hard pull on the
transducer.
When the elbow is unlocked and
no control signals are present, the el-
bow is in a powered free swing mode.
The free swing is powered (w1like the
free swing modes of the Boston Digi-
Figure 20 Motion Control Utah Arm 2. Shown above is the complete elbow-forearm as- tal Arm System and the Hosmer NY
sembly. In the lower photograph, the forearm cover has been removed, revea ling the Electric Elbow) because the drive
drive mechanism and the electronic prehensor controller (at the distal end of the drive transmission of the Utah elbow re-
assembly). The 12-V battery pack is in the elbow cap below the humeral turntable.
(Courtesy of the Northwestern University Rehabilitation Engineering Research Program.)
mains engaged dming free swing. To
overcome the electromechanical iner-
tia of the drive mechanism, the motor
changes in the control signals to Whenever the elbow is locked, the actively flexes and extends the elbow,
achieve fast movements, yet smoother same myoelectric sources used to thus drawing battery current, as the
response for slower-changing lower control the elbow are automatically arm is swung. The action of the mo-
amplitude signals used in more pre- channeled to proportionally control tor is controlled by the response of a
cise movements. opening and closing of an electric load cell transducer to the torque ex-
Locking of the elbow is engaged prehension device. Unlocking the el- erted on the forearm during body
whenever it is held stationary for a set bow by rate control returns control to movements.
period of time (the length of which the elbow without inadvertent opera-
can be adjusted) or when a momen- tion of the prehensor. If an electric Commentary on Electric
tary switch is actuated. The elbow has wrist rotator is used, an additional Elbows
22 locked positions throughout its control switch is required to switch Although the design and performance
range of motion. Unlocking can be ef- control between the prehensor and characteristics of electric elbows have
fected in several ways: by rapid co- rotator while the elbow is locked. been improved, the performance level
contraction of the controlling mus- When the elbow is unlocked, neither remains below that of the physiologic
cles (rate control), by a slower the prehensor nor the rotator can be elbow. Although it is not yet possible
contraction of at least one muscle activated. This control scheme is re- to truly restore elbow function with
(threshold control), or by actuation of ferred to as sequential control because these prosthetic components, electric
the same momentary switch that can the same myoelectric sites control elbows can provide valuable function.
be used for locking. Lock control by each of the devices and control is se- There are significant differences
the switch is always available. Rate quenced, under the direction of the among the elbows available. Conse-
control or threshold control of un- user, from one device to another. quently, the many attributes of each
locking are mutually exclusive and are The second control option is the type- including factors such as
determined by an adjustment in the ServoPro controller. This control con- weight and size, control options, inte-
electronics. figuration uses a strain-gauge trans- gration into a complete prosthesis,

Figure 21 LTI-Collier Locking Shoulder

Joint implemented in a left shoulder dis- Figure 22 Liberating Technologies Motor-Drive Lock/Unlock Actuator and LTI -Collier
articulation prosthesis. (Courtesy of the Locking Shoulder Joint. On the right, the humeral attachment plate is abducted to show
Northwestern University Rehabilitation the motor and drive screw of the actuator. (Courtesy of the Northwestern University Re-
Engineering Research Program.) habilitation Engineering Research Program.)
and capacity for being finished in a over so that gravity pulls the arm into providing additional benefit to indi-
cosmetically acceptable form-should flexion with respect to the body. When viduals with upper limb amputations.
be considered in the decision to in- the nudge control is released, the lock However, much remains to be done to
corporate one in a fitting. reengages and the shouJder remains develop prosthetic devices and con-
flexed as the user stands upright. trol schemes that parallel physiologic
When t he user cannot manually performance and restore function. Al-
Enhancement of a operate a nudge control or prefers an though advances have been made,
M anual Shoulder alternative way of controlling the new developments are by no means
Joint lock, the nudge control and cable can inevitable. Many factors beyond tech-
be replaced by the Liberating Tech- nologic and conceptual break-
No electric-powered mechanisms for nologies Motor-Drive Lock/Unlock
positioning a prosthetic shoulder throughs must be integrated to create
Actuator (Figure 22). The actuator an environment that supports and en-
JOmt are commercially available. can be operated with a switch or with
However, one locking shoulder joint, courages innovation and provides for
a myoelectrode or force-sensitive re- the transfer of innovation into clini-
the LTI-Collier Locking Shoulder sistor through an electronic control-
Joint, manufactured by Liberating cal practice. The speed with which
ler. If the prosthesis includes the Bos- this chapter is transformed from a
Technologies, can be fit with an elec- ton Digital Arm System, the actuator
tric lock actuator. This is a two- state-of-the-art review to a historical
can be controlled through this system footnote will be a measure not only of
degree-of-freedom shoulder JOtnt with an appropriate input transducer.
(Figure 21). The adduction-abduction the technologic advances in our cul-
axis is hingelike with adjustable fric- ture but also of the vitality and ear-
tion; however, the flexion-extension Summary nestness of the community working
axis can be locked in 10° intervals. to improve the capabiJities of persons
Significant changes have occurred in who use upper limb prostheses.
In manual operation, the flexion- the types and characteristics of
extension lock is spring-loaded to re- electric-powered upper limb compo-
main locked. Actuating a nudge con- nents since the publication of the sec- References
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to swing relatively freely. While the improved performance characteris- ternally powered hands. Bull Prosthet
joint is held unlocked, the user can flex tics, and greater versatility in the im- Res 1969;10-12:118-155.
the shoulder joint by simply leaning plementation of control strategies are 2. Childress DS: Artificial hand mecha-

b
p
170 Section II: The Upper Limb .
nisms, in Proceedings of the Mechanisms Department of Engineering, 1947. Mountain Bioengineering Symposium.
Conference and International Sympo- 15. Toth PJ: Hand Function Differentiation. Columbia, MO, Instrument Society of
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Fairfield, NJ, American Society of Me- 1991. Thesis. 27. Prou t W: The New York Electric El-
chanical Engineers, 1972, pp 1- 11. 16. van Lunteren A, van Lunteren- bow, the New York Prehension Actua-
3. Nader M: The arti ficial substit ut ion of Gerritsen GHM, Stassen HG, Zuithoff tor, and the NU-VA Synergetic Pre-
missing hands with myoe lectrical MJ: A field evaluation of arm prosthe- hensor, in Atkins DJ, Meier RH (eds) :
prostheses. Clin Orthop l 990;258:9-17. ses fo r uni lateral amputees. Prosthet Comprehensive Management of the
4. Alpenfels EJ: T he anthropology and Orthot Int 1983;7:141 - 151. Upper-Limb Amputee. New York, NY,
social significance of the human hand. Springer-Verlag, 1989.
17. Taylor CL: The biomechanics of the
Artif Limbs 1955;2:4-2 l. normal and of the amputated upper 28. Engen TJ, Spencer WA: Development of
5. Simpson DC: The functioning hand, extremi ty, in Klopsteg PE, Wilson PD Externally Powered Upper Extremity
the human advantage.J R Coll Surg (eds): Human Limbs and Their Substi- Orthotics, Final Report. Houston, TX,
Texas Institute for Rehabilitation and
Edinb 1976;21:329-340. tutes. New York, NY, McGraw-Hill
Research, 1969.
6. Simpson DC: Functional requirements International Book Co, 1954.
29. Morrey BF, Askew LJ, An KN, Chao
and systems of control for powered 18. Matbiowetz V, Kashman N, Volland G,
EY: A biomechanical study of normal
prostheses. Biomed Eng 1966; I :250- Weber K, Dowe M, Rogers S: Grip and
functional elbow motion. J Bone Joint
256. pinch strength: Normative data for
Surg Am 1981;63:872-877.
7. Northmore- Ball MD, Hege r H, Hunter ad ults. Arch Phys Med Rehabil 1985;66:
69-74. 30. Palmer AK, Werner PW, Murphy D,
G: The below-elbow myo-electric
Glisson R: Functional wrist motion: A
prosthesis: A comparison of the Otto 19. Imrhan SN: Trends in finger pinch
biomechanical study. J Hand Surg Am
Bock myo-electric prosthesis with the strength in children, adults, and the
1985; 10:39-46.
hook and fw1ctional hand. J Bone Joint elderly. Hum Factors 1989;31:689-701 .
31. Safaee-Rad R, Shwedyk E, Quanbury
Surg Br 1980;62:363-367. 20. Taylor CL: Control design and pros-
AO, Coope r JE: Normal functional
8. Chan KM, Lee SY, Leung KK, Leung thetic adaptations to biceps and pecto-
range of motion of upper limb joints
PC: A medical-social study of upper ra l cineplasty, in Klopsteg PE, Wilson
during performance of three feeding
limb amputees in Hong Kong: A pre- PD (eds): Human Limbs and Their Sub-
activities. Arch Phys Med Rehabil 1990;
liminary report. Orthot Prosthet 1984; stitutes. New York, NY, McGraw-Hill
71:505-509.
37:43-48. International Book Co, 1954.
32. Doubler JA: An Analysis of Extended
9. Billock JN: Upper limb prosthetic ter- 21. Michael JW: Upper limb powered Physiological Proprioception as a Control
minal devices: Hands versus hooks. components and controls: Cu rrent Technique for Upper-Extremity Prosthe-
Clin Prosthet Orthot 1986; 10:57-65. concepts. Clin Prosthet Orthot 1986;10: ses. Eva nston, JL, Northwestern Uni-
10. Millstein SG, Heger H, Hunter GA: 66-77. versity, 1982. Dissertation .
Prosthetic use in adult upper limb 22. Puchhammer G: The tactile slip sen- 33. Komi PV: Relationship between mus-
amputees: A comparison of the body sor: Integration of a miniaturized sen- cle tension, EMG and velocity of con-
powered and electrically powered sory device on a myoelectric hand. traction u nder concentric and eccen-
prostheses. Prosthet Orthot Int 1986; 10: Orthop-Tech Quarterly 2000;7- l 2. tric wo rk, in Desmedt JE (ed): New
27-34. 23. Dietl H, Grope] W: Versorgung nach Developments in Electromyography and
11. Kemp MC: Design and development Teilhandamputationen mit myoelek- Clinical Neurophysiology, Vol 1. Basel,
of an electrically powered prosthetic trischen Komponenten. Orthop-Tech Switzerland, S Karger AG, 1973.
gripper, in Proceedings of the First Inter- 2001;1:21-23. 34. J0rgensen K, .Bankov S: Maximum
national Workshop on Robotic Applica- 24. Childress DS: An approach to powered strength of elbow flexors with pr-
tions in Medical and Health Care. Ot- grasp, in Gavrilovic M, Wilson AB Jr onated and sup inated forearm, in
tawa, Canada, National Research (eds): Proceedings of the Fourth Interna - Medicine and Sport, Vol 6, Biomechanics
Council Canada, 1988, pp 19.1- 19.5. tional Symposium on Advances in Exter- Il. Basel, Switzerland, S Karger AG,
12. Datta D, Kingston), Ronald J: Myo- nal Control of Human Extremities. Du- 1971.
electric prostheses for below-elbow brovnik, Yugoslavia, Yugoslav 35. Pertu.zon E, Bouisset S: Maximum
amputees: The Trent experience. Int Committee for Electronics and Auto- velocity of movement and maximum
DisabilStud 1989;11:167- 170. mation, 1972, pp 159- 167. velocity of muscle shortening, in Med-
13. Schlesinger G: Der Mechaniscbe Auf- 25. Chit.dress DS, Gral111 EC: Development icine and Sport; Vol 6, Biomechanics II.
bau der ki.i11Stlichen Glieder, in Er- of a powered prehensor, in Proceedings Basel, Switzerland, S Karger AG, 1971.
satzglieder und Arbeitshilfen, Part 2. ofthe 38th Annual Conference ofEngi- 36. Tanenbaum SJ: The Boston Elbow-
Berlin, Germany, Springer-Verlag, neering in Medicine and Biology. Chi- Health Technology Case Study 29. Re-
1919. cago, [L, The Alliance for Engineering port OTA-HCS-29. Washington, DC,
14. Keller AD, Taylor CL, Zahm V: Studies in Medicine and Biology, 1985, p 50. U.S. Congress, Office of Teclrnology
to Determine the Functional Require- 26. Childress DS, Strysik JS: Controller for Assessment, 1984.
ments for Hand and Arm Prostheses. Los a high-performance prehensor, in Pro- 37. WLlliams TW: Use of the Boston elbow
Angeles, CA, University of California, ceedings of the 23rd Annual Rocky for high-level amputees, in Atkins DJ,

Me ier RH (eds): Comprehensive Man- 39. Sears HH, And rew JT, Jacobsen SC: and termi nal device, in Atkins DJ,
agement ofthe Upper-Limb Amputee. Cli nical exper ience with the Utah Ar- Meier RH (eds) : Comprehensive Man-
New York, NY, Sprin ger-Verlag, 1989. ti ficial Arm , in The Canadian Associa- agement of the Upper-Limb Amputee.
38. Jacobsen SC, Knutti DF, Joh nson RT, tion of Prosthetists and Orthotists Year- New York, NY, Springer-Verl ag, 1989.
Sears HR: Development of the Utah book. 1984, pp 30-33.
artificial arm. IEEE Trans Biomed Eng 40. Sears HH, Andrew JT, Jacobsen SC:
1982;29:249-269. Experience with the Utah Arm, band,
cs
d-
1.
ow
1J,

b
Control of Limb Prostheses
Richard F. ff Weir, PhD
Int roduction
This chapter deals primarily with limbs, discussion centered primarily limb components. The gripping force
control of externally powered on interface loads, suspension, and of this hand is increased automati-
(electric-powered) prostheses. Pros- alignment because the lower limb cally if a sensor detects that the object
theses that are entirely cable-actuated must bear significant loads and its ac- being held is slipping out of the grip.
and body-powered are covered in tivity is highly repetitious and styl- Reflex action in a prosthesis ( up-
chapter 9, as are the various control ized. However, recent success using per or lower limb) can red uce the
schemes of cable-operated prostheses. microprocessors in artificial knee mental load on the user by removing
Nevertheless, cable-operated systems joints has heightened the consider- the user from the control loop while
will also be considered in this discus- ation given to the control of lower improving performance of the artifi-
sion because of the many ways they limbs. cial limb. Figure 1 shows how feed-
can be used in conjunction with ex- Microprocessor control of a knee back occurs in human-prosthesis sys-
ternally powered components. Partic- p rosthesis is often a reflex control that tems. With control interface feedback,
ularly with prostheses for high-level is. more or less automatic. By moni- the operator receives feedback via the
unilateral and bilateral limb loss, the toring the state of the knee in stance same channel tl1rough which tile
systems of choice often use hybrid phase (how much it is bent, which di- prosthesis is controlled (eg, tl1e con-
control (cable, myoelectric, switches, rection it is bending, and how fast it is trol cable of a body-powered prosthe-
or some combination of these or bending) and by monitoring the loca- sis) . Because control interface feed-
other methods) and hybrid power tion of the ground-reaction force back is usually in a form easily
(electric- and body-powered). Addi- with respect to the knee, a properly interpreted by ilie user, it can be in-
tionally, powered systems can be set programmed microprocessor can ad- terpreted at a subconscious level, re-
up to emulate cable systems as a for m just knee stiffness to keep the user ducing the mental burden on the
of boosted control. For individuals from falling or to facilitate the wa lk- user. Artificial reflexes are closed
with high-level bilateral limb loss, we ing cycle. The same can be done dur- loops witl1i11 the controller/prosthesis
often recommend fitting one arm ing swing phase. Microprocessor con- mechanism itself that seek to remove
with body power and the opposite trol at the knee provides a type of tl1e operator from the control loop al-
limb with electric powel".1 Conse- artificial reflex control that occurs au- together, and hence also relieve the
queutly, any general discussion of tomatically. The user is not aware of mental load. Such systems use on-
control systems for individuals with the control decisions tl1at are con- board intelligence to automatically re-
arm loss should include both body stantly being made. Artificial reflex spond to some external sensor input.
power and cable control. control can be particularly advanta- Incorporation of artificial reflexes in
Until fairly recently, discussions of geous in the control of knee stiffness many kinds of prosthetic limbs will
limb prosthesis control generally fo- during walking. Artificial reflex con- likely increase over the next decade.
cused on upper limb prostheses. Only trol can also be effective in upper Most powered upper limb prostheses
rarely was control of lower limbs t he limb control systems. The automatic receive feedback primarily through
topic (an exception was emphasis on control of prehension force in the visual feedback with some assistance
extension of the thigh to control ex- Otto Bock SensorHand (Otto Bock, from incidental feedback (feedback
tension of a knee mechanism in Duderstadt, Germany) is one example that is incidental rather than by de-
transfemoral prostheses) . Witl1 lower of artificial reflex control in upper sign, such as motor whine, prosthesis

b
•
r----------------------------------------~ neous and coordinated control of
I Artificial reflexes : multiple functions, (5) near-instan-
I I
I I
Control I : taneous response, (6) noninterference
interface
,
!
, Closed loops
!, with the individual's remaining func-
!I :I :I tional abilities, and (7) a natural ap-
• I
I pearance and quiet movement.
Human I
operator ~ " m ,l_eo_n_

I' I
tro_,_,e_r J :
I
First, the system should have low
mental loading or subconscious con-
L----------------------------------------J trol; that is, the prosthesis can be used
Complete prosthesis
Visual feedback, without much thought by the user.
incidental feedback,
Successful control systems enable in-
Supplementary - - - - - - - - - - - - - - - - - - - - - - '
sensory feedback dividuals to engage their artificial
limbs almost subconsciously, the way
Figure 1 Feedback in human-prosthesis systems. people commonly use their limbs.
The prosthesis should serve rather
vibration, socket forces, etc). Supple- tibial prosthesis with a foot and the than dominate the user. The user
mentary sensory feedback may be transradial prosthesis with a cosmetic should be able to think about other
provided through the use of vibra- hand are essentially similar in struc- things while using the prosthesis. This
tions to the skin, pressure to the skin, ture. Both have passive terminal de- kind of control will require proprio-
electrical stimulation of the skin, by vices, one a passive foot and the other ceptive and sensory feedback of the
auditory cues, and by other means. a passive hand. However, if the pas- right modality, which often can be
Because these methods are supple- sive hand is replaced by an active obtained simply by making the limb
mentary to normal sensory feedback hand-perhaps one controlled myo- an extension of the most distal re-
paths, however, the feedback is not electrically-the focus of attention is maining joint of the body, as is the
presented in a physiologicaJly useful usually the control of opening and case with transtibial and transradial
manner. Closed loops are feedback closing the hand . Hence, myoelectric prostheses. Artificial reflex actions,
pathways to improve the performance control can divert attention from the such as those of the SensorHand, will
of the mechanism itself, such as posi- fact that the elbow joint is largely re- also help in1prove subconscious con-
tion or velocity control. Microproces- sponsible for the somewhat natural trol by transferring the effort involved
sors are relatively inexpensive and can control of the transradial prosthesis, in monitoring the device from the
run on low power in many prosthetic just as the knee is the source of the user to the device controller.
applications. A key issue for the suc- natural control of the transtibial Second, the control should be
cess of these types of automatic con- prosthesis. The next decade of trans- user-friendly, or simple to learn to
trol systems is user confidence. Users tibial prostheses may well have elec- use. Learning to control the prosthesis
will not reUnquish control unless they tron ic controls of the ankle and foot, should be intuitive and natural. This
have high confidence in the system. which may similarly divert attention kind of control should enable people
The mechanisms must also be fail- from the importance of the knee joint to learn quickly and easily how to use
safe so that limbs will not collapse in providing natural control of the the prosthesis. This is one reason why
in the event of electronic controller myoelectric control for the person
transtibial prosthesis.
failure. with a transradial amputation has
Several similarities exist between been so successful. Physiologically
upper limb prosthesis control and Goals for Limb and intuitively appropriate control
lower limb control. An individual Prosthesis Control actions are used to control the artifi-
with a transtibial prosthesis, for ex- cial hand because the extrinsic mus-
ample, has awareness (mostly via the Several highly desirable attributes of cles of the hand reside in the forearm.
intact knee joint) of where the artifi- control systems for limb prostheses This concept of appropriate control
cial limb is in space, how fast the merit discussion. Although some may sites is at the heart of the surgical
shank is moving, and what forces are be difficult if not impossible to procedme advanced by Kuiken and
acting on the limb. The transradia1 achieve in practice, keeping these ide- associates2 to reinnervate a section of
cosmetic prosthesis (or myoelectric als in mind is important to stimulate muscle tissue with nerves that control
prosthesis) acts in a similar fashion. continued improvement and develop- the forearm musculature.
The intact elbow joint informs the ment of control systems. These at- Third, independent control of a
user of the position of the arm in tributes are ( 1) low mental loading or function should be provided without
space and its angular velocity and subconscious control, (2) user- activating or interfering with other
provides information concerning friendliness, (3) independence in control systems of a multifunctional I
forces acting on the limb. The trans- multifunctional control, (4) simulta- prosthesis. For example, a person

Chapter 12: Control of Limb Prostheses 175
with prostheses on both arms should sirable movements are compliant, si- arm prosthesis were used in this way,
be able to use each limb indepen- lent, and do not appear mechanical. the battery would be depleted rather
dently. Operation of one prosthesis Although this list of desirable con- quickly even though no external work
should not cause unintended activity trol attributes for prostheses can cer- is being performed. A design compro-
of the prosthesis on the opposite side. tainly be extended, many are difficult mise such as a mechanically locking
A common example of failure of in- to achieve with current technology elbow would be appropriate. Al-
dependent action is in typical cable- and knowledge of human-machine though this control choice of a lock-
operated, body-powered trans- control. In reality, tlnese attributes are able joint is not biomimetic, it is
humeral prostheses with a voluntary essentially control attributes exhibited practical.
opening hook. If the user attempts to by the human hand/arm system. The This chapter concentrates on con-
lift a heavy load, the hook tends to ideal system would be biornimetic, trols and systems t hat enable people
open during the lifting process. In bi- but because such a system is not feasi- to use prostheses primarily as assistive
lateral cable-operated prostheses, flex- ble at this time from an engineering tools. The goal is to help tlnose with
ion of one arm can generate unin- standpoint, prosthetists and designers upper lirnb loss at least regain basic
tended flexion in the other arm as must decide where to focus their ef- functions such as reaching, grasping,
well. forts. and holding.
Fourth, coordinated, simultaneous
control of multiple functions in effec-
Design Control Variables
tive and meaningful ways, without ex-
cessive mental effort, is one of the Considerations Joints of a prostl1esis need to move
freely so tlnat the limb can be maneu-
amazing aspects of control of the h u - What should be controlled by pros-
vered easily into tlne desired position
man hand and arm. This capability, thesis control systems depends
for operation. It may also be advanta-
which is currently not available in heavily on the philosophic approach geous to control tl1e rate of move-
practical prostheses, subsumes many taken to artificial limb design. If the ment (velocity) to the desired posi-
of the other desirable attributes. objective is to design an artificial arm tion. Once the limb is in position,
Fifth, prosthetic systems should re- that emulates a human arm as closely prehension force can be controlled.
spond quickly to inputs so tlnat time as possible, a designer/developer And when a desirable position is
delays between input and output are might want to control joint compli- reached, it may be advantageous to
not noticeable to the user. All func- ance3'4 and other variables in an at- lock specific joints, perhaps all of
tions should be directly accessible to tempt to make tlne prostlnetic limb ex- them. Thus, tlne variables to be con-
the user, without perceived time de- h ibit several characteristics of tlne trolled in arm prostlneses include po-
lays. Delays greater than 100 ms are human arm/hand system. However, if sition, velocity, prehension force, and
s readily perceptible. Simultaneous ac- at tllis stage of arm/hand prosthesis join t status (locked or free).
s tion of various joints may require development good biomimetic de- In many situations (eg, pushing), it
e even quicker actions in a prosthesis; signs are not clinically viable, then is advantageous for a prosthetic arm
e 50 ms is a desirable objective. other approaches need to be consid- to be completely rigid (all joi nts posi-
y Sixth, a control system should not ered, at least for the near future. If de- tively locked). In otlner instances, such
[l sacrifice the user's remaining func- signers of prosth eses truly wan t to as walking, tlne joints of an upper
.s tional abilities. Control systems h elp people with limb loss over the limb prostlnesis need to be free so that
y should never encumber any natural next several decades, they should take tlne artificial limb(s) can swing some-
,I movements that can be applied to a clinical approach and design pros- what naturally with the gait cycle.
useful purposes. In general, it is un- theses that effectively are tools that Control of upper limbs usually
wise to sacrifice any useful natural assist with activities of daily living. 5 It brings to mind ftmctions such as
l. body function for tlne control of a may be desirable for the tool to look positioning (reach ing), grasping/
>I prosthesis. The prosthesis should be like an arm/hand as well as function releasing, and lifti11g/holding. How-
i1 used to supplement, not limit, avail- like one, but appearance and function ever, the ability to make joints rigid or
d able functional ability. sometimes conflict. free is also a n important function to
>f Last, tl1e control system shouJd Practical issues of prosthesis de- be controlled in practical arm pros-
)1 have a natural appearance and quiet sign also support the "tool" approach theses. In the future, continuous con-
movement. A control system should to arm prostheses. When an individ- trol of the stiffness of joints from tlne
a not detract from the appearance of ual stands erect and holds a heavy ob- free state to the locked state may be
Jt the limb, either statically or dynami- ject in the hand with the elbow bent possible. At the present time, how-
cally. Aesthetically pleasing move- at 90°, for example, muscular action ever, only the free (ie, very low fric-
al ments affect prostlnesis appearance and expenditure of energy is required tion) and locked (ie, extremely high
just as size, shape, and color do. De- at tlne elbow. If an electric-powered friction) conditions are practical to

p
or attached in some way to the head,

arms, or hands. Simpson7 called this
approach extended physiological
proprioception (EPP). This principle
is used in transtibial prostheses, in the
walking cane, in the long cane (for vi-
sion impairment), in mouthsticks,
and, of course, by anyone who plays
tennis, squash, baseball, or golf, or
who uses hammers or screwdrivers.
T his powerful principle provides a
practical guide for building and con-
trolling Limb prostheses. The ap-
proach is also useful in designing and
developing aids for individuals to
cope with various disabling condi-
tions. New York artist Chuck Close,
Figure 2 Different sets of muscles can be who became paralyzed at the height
used to achieve similar resu lts, illustrating of his career, was told by his therapist
a principle described by Bernstein 6 in that he didn't paint with his hands, he
1967. Th e upper signature was written
using primarily muscles of the hand. In
painted with his brain. Some observ-
the center photograph, the correspond- ers believe that Close paints even bet-
ing signature was generated primarily ter without control of his hands.
with muscles of t he shoulder. The bottom
photograph demonstrates creation of the
lower signature with primarily leg and Sources of Body
torso movements transmitted to the
chalkboard by the semirigid connection Inputs to Prosthesis
of chalk, teeth, and neck. The lower sig- Controllers
nature could also have been written us-
ing neck motions. This signature is not as T he human body generates a variety
smoothly written because of the friction of control signals that can be used to
between the chalk and the board and
operate prostheses. 8 Inputs typically
lack of a mouthpiece to stabilize the
chalk in the mouth. come from muscular activity-di-
rectly, indirectly through joints, and
indirectly through by-products of
control, so this kind of joint stiffness hammer nails or push heavy objects muscular contraction (eg, myoelec-
control is emphasized in this chapter. with the prosthesis, provided the Limb tricity, myoacoustics, muscle bulge,
Extremely high friction refers to is fairly rigid with respect to the torso. tendon tightening, changes in muscle
joints that are mechanically locked. Torso motion can be used quite natu- hardness/softness with contraction, or
Friction joints that can be adjusted to rally to strike objects such as nails changes in the electrical impedance of
different resistance, particularly fo r with a prosthesis that is rigid and muscle mass with contraction). Sig-
individuals with high-level amputa- firmly attached to the torso. Similarly, nals also can be obtained from brain
tions, generally do not function well. if the joints of a shoulder disarticula- waves (electroencephalograms), voice,
'When a person with an amputation tion prosthesis are locked, the natural feet, eyes, and tongue; however, very
wants to position a joint, the friction motion of the torso can be extended few of these sources of control have
needs to be low; when the user wants through the prosthesis to produce proved practical in daily applications
the joint to remain fixed in position rather natural control (assuming se- with artificial limbs. The most com-
under load, the friction needs to be cure grasp). Figme 2 illustrates the mon control options (Table 1) are
high. It is extremely difficult to meet principle described by Bemstein6 that classified as two types, biomechanical
both of these needs with a single fric- similar results can be achieved by dif- and bioelectric/acoustic.
tion setting. Accordingly, joints that ferent sets of muscles. Holding the The biomechanical sources listed
can be set in free or locked states are chalk rig.idly, the author can write his in Table l have been used extensively
recommended. name by moving the torso with the with good results for control of body-
If the elbow and wrist of a trans- legs. lt is well known that some paint- powered prostheses. This kind of con-
humeral prosthesis are locked and the ers paint extremely well using stick trol is somewhat similar to that used
grasp is secure, the user can easily extensions (brushes) in their mouth by a pilot in a stunt plane. Through a

Chapter 12: Con trol of Limb Prostheses 177
control stick and cables, the pilot can

easily control flight surfaces of the TABLE 1 Control Options
aircraft. The cables provide feedback Biomechanical Sources
on the position, velocity, and force as- Movement/force from a body joint or multiple joints (position, force/pressure)
sociated with the flight surfaces. The • Chin and head force/movement
controller enables the airplane and pi- • Glenohumeral flexion/extension
lot to be somewhat united. Another • Glenohumeral abduction/adduction
• Biscapular and scapular abduction
illustration of this kind of control
• Shoulder elevation/depression
through cables is the hand brakes of a • Chest expansion
bicycle. • Elbow or wrist movement
The same kind of inputs can be Direct force/motion from muscle
used with some powered prostheses • Force/motion from muscle w ith a tunnel cineplasty
(boosted control). In fact, increased • Force/motion from skin that is adherent to underlying muscle
flexibility can be obtained for these • Krukenberg surgical procedure (long transradial amputation)
inputs with powered prostheses be- BioelectridAcoustic Sources
cause force/excursion requirements Myoelectric potentials (muscle electricity)
can often be relaxed considerably Myoacoustic (muscle sounds)
when using powered components (eg, Neuroelectric potentials (neuron and nerve signals)
t with power steering in automobiles).
Biomechanical inputs can be inter- ing to use transducers, and sometimes Integrated Versus Modular
faced with prostheses in many ways even simple switches, with control Prosthetics Systems
other than using Bowden cables; how- systems for which they were not de-
ever, not all of these methods provide One way to approach prosthetic limb
signed or are not compatible. Specifi-
the level of feedback that Bowden ca- control systems is to break down up-
cations for voltage amplitude, voltage
bles produce. Basically, a force or per limb prosthetics systems into
polarity, electrical impedance, and
movement of a body part (eg, resid11aJ joints (powered and nonpowered
wiring connections must be met be-
limb, chin/head, etc) is used to move components), control systems, trans-
fore transducers can be inserted into
a mechanical lever to operate an elec- ducers, and other parts rather than
control systems for which they may
tric switch, activate an electronic considering the system as a whole. A
not originally have been designed.
y switch, push on a pressure-sensitive key advantage of the modular ap-
·o Rocker and push-button switches
transducer, or otherwise operate some proach is flexibility in system design.
can be operated easily by pressing
ly kind of position, force, or touch/ Modularity is practical because differ-
against th em with a body movement.
1- proximity transducer. ent parts can be substituted as a cli-
1d Switches are easy to use, simple, and
ent's needs change. However, the
:if Transducers inexpensive. In addition, their assem- modular approach may not attain the
c- bly into a whole prosthesis is fairly in- highest functional goals. Only systems
Many types of transducers can det,e ct
;e, tuitive. Unfortunately, switch control designed from an integrated stand-
biomechanical signals (force or ex-
le cursion) and turn them into electrical is not always sufficient to achieve point can truly be optimized. Systems
:ir signals for control purposes. These good prosthesis control. that use force input from the user to
of types include mechanical switches, Switches also can provide multiple the controller, for example, need pow-
g- which require both force and excur- functions from one source. One fre- ered components with very low back-
in sion to turn on or off, sensitive quently used push-button switch pro- lash and very low static friction if
:e, transducers, which change their resis- duces one function when pushed part they are to work well without exhibit-
ry tance when force is applied yet have way and another function when ing limit cycle behavior. 9
.ve essentially no excursion (isometric); pushed in completely. In this manner,
ns and excursion transducers, which the two functions of a powered pros- Myoelectric Control
n- measure distance but require essen- thetic joint or prehensor can be con- Myoelectric control is the control of a
tre tially no force. Some of these trans- trolled with a switch mechanism that prosthesis or other system through
cal ducers are described in greater detail is activated by only one control the use of "muscle electricity." The
in chapter 11. source. Switch inputs can be arranged control source is a small electrical po-
:ed with electronics so that codes can be tential from an active muscle. This
ely Switches used to produce certain prosthetic electrical potential is electronically
iy- Electrical switches are applicable to functions. A wide variety of control processed to activate a switch control-
>n- many prosth etic systems and can of- schemes are possible with simple ler or a proportional controller of
;ed ten be used interchangeably. However, switches and electronics though not power to an electric motor, which in
ha care must be exercised when attempt- all are practical. turn drives the prosthetic system (eg,

-
sively in tl1e literatU1·e. Good technical
sources for information in this area
are the review of myoelectric control
by Parker and Scott 10 and the discus-
EMG sion of myoelectric signals by Basma-
Rectified or
,AAAIIAAA other nonlinear ,..___ _,., Fllter jian and DeLuca. 1 1 Scott 12 authored
vvrnvrvv operation Rectified circuit Smoothed
EMG DC voltage an elementary introduction to myo-
(envelope)
Differential electric prostheses, including control,
bandpass and a comprehensive bibliography
amplifier
concerning myoelectric control of
Figure 3 Diagram of myoelectric signal (EMG) processing in a typical myoelectric con· limb prostheses was prepared by Scott
trol system. Three "dry" metal electrodes are always associated with each differential and Childress. 13
amplifier. The small AC potential from the muscle is amplified, band limited, and The use of myoelectric control in
changed into a DC potential by fu ll-wave rectification, squaring, root mean squaring, or
arm prostheses has increased dramat-
some other appropriate nonlinear processing. In a typical circuit, this DC potential is
commonly smoothed with a low-pass filter to obtain the envelope of the EMG signal. ically during the last two decades. Al-
The smoothed DC voltage can be compared in a logic circuit with a threshold voltage. If iliough some may consider tl1is tech-
the smoothed DC voltage is greater than the threshold voltage, power is supplied to the nique a result of space-age electronics
prosthesis motor; if not, the motor remains off. and integrated circuits, in reality the
first myoelectric control system was
hand or elbow). Muscle electricity is a Just as with an ECG, with a myo- built in Germany in the 1940s. 14 The
by-product of muscle action, just as electric prosthesis, special care must concept is thus 60 years old, much
mechanical noise is a by-product of be taken to reduce the influence of older than the solid-state electronics
an internal combustion engine. The environmental electrical signals such tl1at made the method ultimately
electrical signal may be picked up as broadcast waves, fluorescent lights, practical. The early German system
with electrodes on the surface of the motor arcing, and power lines iliat and an early British system 15 were de-
body as well as internal wire/needle may cause the prosthesis to operate signed with vacuum-tube electronic
electrodes or telemetry implants. Sur- inadvertently. These interference sig- technology. British scientists 16' 17 were
face electrodes are currently the only nals may be many times larger than instrumental in advancing the con-
practical way to receive myoelectric the myoelectric signal itself. A typical cepts of myoelectric control early on
surface EMG may have a peak-to- and constructed some novel circuitry.
signals for prosthesis control because
peak amplitude of around 100 µV, Soviet scientists were ilie first to de-
the electrodes are used for long peri-
whereas noise signals may be a thou- sign a transistorized myoelectric sys-
ods of time every day and hence must
sand times greater. T he electrical tem iliat could be carried on the
be benign to skin and tissues. The
noise can be eliminated for the most body. 18 CoJJaboration between a Ger-
surface method of detection of mus-
part by good electron ic circuitry tl1at man company, Otto Bock, and an
cle activity is aptly illustrated in the
features differential amplification, fil- Austrian hearing aid company, Vien-
standard electrocardiogram (ECG),
tering, and thresholding, and by good natone, led to tl1e first transradial myo-
which is the electromyogram (EMG)
electrode pos1t10ning and design electric system commercially available
of the heart muscle. A gel-type elec- in the United States. Many other com-
techniques. To reduce electrical noise
trolyte is usuaJJy applied to the skin pick-up, the electronic amplifiers are mercial myoelectric systems have fol -
during ECG procedures to lower the often packaged together with the lowed (see chapter 11).
electrical resistance of the skin. With metal electrodes so that the connect- Because no control inputs wiiliin
prosthesis control, however, gel elec- ing wires between ilie electrodes and our common daily experience are
trolyte is not recommended because ilie amplifiers are extremely short analogous to those of myoelectric
of possible skin irritation with long- (Figure 3) . When ilie electronic am- control, it will be described more fully
term use. Consequently, inert metal plifier or the amplifier and processor here than the more intuitive biome-
electrodes such as stainless steel are electronics are put into a single pack- chanical control approaches. Electric-
usually used in myoelectric prostl1e- age with the metal electrodes on ilie ity from skeletal muscles appears witl1
ses. Altl10ugh they are often called outside, the whole package is often voluntary muscle contraction. This
"dry" electrodes because of the ab- called an electrode; however, only ilie voluntary control is one of the excel-
sence of electrode paste (conductive metal parts that interface with the us- lent attributes of myoelectric control.
gel), they are not truly dry because er's skin are t he actual electrodes. A myoelectricalJy controlled system
the body's own perspiration serves as The characteristics of myoelectric will work only when the person with
a reasonably good electrolyte for tl1e signals and tl1e processing of myo- an amputation generates voluntary
electrodes, eliminating the need for electric signals for use in prosthesis muscle action. Such a system is im-
conductive pastes. control have been described exten- mune to influence from external

forces, prosthesis location, or body cies less than about 10 Hz are often plifiers. Although a correct tipping re-
position/motion. Similarly, myoelec- not amplified to any extent so that sponse is necessary, it is not a suffi-
tric prostheses should be unaffected slow polarization voltage changes that cient test to determine if a myo-
by external electrical interference may occur over time at the electrode- electric prosthesis is functioning
(noise) except for very exceptional ski11 interface are not amplified; this properly.
environmental circumstances. may be of special importance with In a myoelectric system, amplifica-
The myoelectric signal itself is a "dry" electrodes. tion is followed by electronic process-
somewhat randomly shaped signal A myoelectrically controlled pros- ing that usually turns the myoelectric
that comes from the spatial and tem- thesis can only function in its normal signal, an AC potential, into a DC po-
poral summation of the asynchro- fashion when all the electrodes are tential of a given polarity (in Figure 3,
nous firing of single motor units positioned properly on the body. All the DC potential is positive). The en-
withi11 the muscle. It is a kind of electrodes should remain in contact velope of this DC potential goes up
electrical interference pattern that re- with the skin at all times during and down as the myoelectric signal
sults from the electrical depolariza- prosthesis use. If electrodes lose con- increases or decreases in amplitude,
tion of thousands of muscle fibers tact with the skin, lack of control that is, as the muscle action increases
(perhaps several hundred per motor and/or electrical interference may oc- or decreases. Electronic logic circuitry
unit for typical forearm muscle ac- cur. For this reason, the prosthetist can be designed so that if the DC po-
tion) when they are activated by mo- should fabricate a diagnostic prosthe- tential is greater than some threshold
toneurons. This electric wave can only sis with a clear plastic socket that al- voltage (such as 1.0 V), then the cir-
be described statistically because its lows observation of the electrodes cuit will turn on an electronic switch
amplitude and frequency are con- while the prosthesis is used in differ- that allows electric power to flow to
stantly vaJying, even when an indi- ent positions and under various the prosthesis motor. T he result of
vidual holds muscle action as con- loading conditions. The socket should contracting a muscle to a certain level
stant as possible. However, the general be designed so that the electrodes thus results in power delivery to the
range of amplitude and the dominant maintain contact with the skin for all driving motor of the hand or arm. If
c frequency of a typical surface signal reasonable external load applications, the DC potential falls below the
e are both 100 (100 µV for peak-to- prosthesis positions, and movement threshold, the power to the motor is
peak amplitude and 100 Hz for the velocities. turned off.
0 approximate frequency of maximum The body acts as an antenna, pick- In myoelectric control, power to
{, energy). The voltage of a typical stu - ing up electrical noise from the envi- the motor is provided by the voltage
face EMG is roughly one million ronment. Consequently, "tipping" and current from the battery, not the
times less than that of electrical wir- (touching the exposed electrodes with electricity from muscles. The myo-
.e ing in a typical home in the United the fingers) introduces electrical noise electric signal is used only for control
States. This voltage can be amplified through the fingers to the electrodes purposes. In actuality, the electronics
n by increased muscle action or reduced and into the electronics. There are no of myoelectric control systems vary
l- all the way to zero when the muscle myoelectric signals in the fingertips with each manufacturer. Some have
>- is inactive. There is very little energy because there are no muscles in the circuits that enable the power to be
le in a surface EMG greater than about fingers. The "tipping" response should applied to the motor in a manner
1- 400 Hz. not be i11terpreted to mean that the proportional to the myoelectric signal
1- In electronic design, amplification electrode is a touch sensor or a pres- amplitude. Some can turn the motor
of the voltage of the surface EMG up sure sensor in regulaJ use; it is not. on and also reverse its direction of ac-
Lil to a level of from 1 to 10 V is fre- When touched, the myoelectric sys- tion (polarity/rotation) while using
re quently desirable. An amplification of tem responds to the stray electrical only one myoelectric control site.
ic 10,000 to 100,000 (1.0/0.0001 or noise present on the body coming Others use two or more myoelectric
Jy 10.0/ 0.0001) is needed to accomplish from radio and television broadcast- control sites to effect action of a mo-
e- this increase. To avoid noise amplifi- ing, fluorescent lights, electric motor or motors. The system depicted in
c- cation as much as possible, bandpass tors, etc. Tipping is often used to Figure 4 is a typical transradial myo-
th differential amplifiers are used so that demonstrate the general action of the electric prosthesis with a generic de-
1is voltages common to the two inputs prosthesis when it is not on the body; sign for a two-site, two-ti.mction myo-
d- (common-mode voltages) are rejected however, an expected response to electric control system.
o!. and so that amplification is most ef- touching the electrodes does not nec- In two-site or multisite EMG sys-
:m fective for frequencies around 100 Hz. essarily mean that tl1e myoelectric tems, after the EMG has been ampli-
ith No amplification is necessary greater system is completely functional. Mal- fied, band-limited, and "enveloped," a
LrY than about 400 Hz for control pur- functioning amplifiers may respond decision block is needed to determine
n- poses because the signal above t:h is to tipping even when they no longer which EMG signal should be used for
1al frequency is relatively low. Frequen- function correctly as differential am- control so that the appropriate mo-

>
Figure 4 A, Use of a transradial myoelectric prosthesis. Th e

syst em uses two myoelectric sites on the residual limb. B, Di-
agram of signal f low in a typical two-site, two-function my-
oelectric hand prosthesis. A two-site system must have a
method of determining which of the two incoming signals
to use to drive the motor. One method is to use a drive sig-
nal proportional to the magnitude of the difference be-
tween the two incoming signals and send it to the motor-
the "most-on" method. An alternative is the "first-on," or
lockout method. With the first-on method, the fi rst signal to
cross an "on " threshold is sent to the motor; any other signal
is ignored, (locked out) until the "on" signal level drops be-
low a second "off" threshold. Bot h on-off (digital) and pro-
portional control of hands are possible.
Differential
bandpass
EMG1 amplifier Smoothed
Rectified ~ - - ~ DC voltage
Rectified or EMG Filter (envelope)
.AAAAU~l
vvvmvvv >-- - - 1 1 . i other nonlinear t - --11~
operation circuit
Decision Electronic
logic motor driver
Differential Prosthesis
bandpass motor
amplifier Smoothed
EMG2
DC voltage
Rectified or Filter (envelope)
,1AUHA4 > - -- - 1~ other nonlinear 1 - --11~
•v mivvv operation circuit
j_
Reference
electrode
B
tors in the prosthesis can be actuated. With a "first-on" or "lockout" strat- standa1·d two-site systems (personal
Traditionally, one of three methods is egy, the first signal to cross a preset communication, with Pat Prigge, Otto
used: a "crisp threshold" strategy, a "on" threshold (hence the term "first Bock Health Care, Minneapolis, MN,
"most-on" or "difference" strategy, or on") is the signal that is used to con- 2003) both use this approach in their
a "first-on" or "lockout" strategy. With trol the motor(s) , and all other signals decision logic.
a crisp threshold, any signal with am- are ignored, or "locked out," even if With a "most-on" or "difference"
plitude greater than a given threshold they cross the threshold voltage, until strategy, the largest amplitude EMG
value is determined to be "on" and re- the first "on" signal has crossed back signal relative to an "on" threshold is
mains "on" tmtil it drops below this below a second "off" threshold. The the signal used to control the mo-
threshold. In a proportional system, Hosmer Dorrance Corporation's tor(s). This method works on a
the amount of amplitude greater than (Campbell, CA) myopulse modula- sample-by-sample basis: no signals
the "on" threshold determines how tion EMG system 19 and Otto Bock are locked out, even after one has
"on" the motor should be. Corporation's (Minneapolis, MN) crossed the threshold. The Utah Arm

Ch apter 12: Control of Limb Prostheses 181
(Motion Control Inc, Salt Lake City, no compelling reason to move from that allowed individuals with ampu-
UT) uses this approach for its deci- myoelectric control to myoacoustic tations to play the piano in a labora-
sion block (m1published data, Motion control. The primary advantage of tory setting.22 This controller incor-
Control Inc, Salt Lake City, UT, 1998). myoacoustic control over myoelectric porated multiple pneumatic sensors
In all these methods, the "on" control may be that the acoustic sen- that were actuated by the movement
threshold and the "off" threshold do sor does not have to be in direct con- of the superficial extrinsic tendons as-
not have to be the same. Different tact with the skin . Its main d isadvan- sociated with individual finger flex-
"on" and "off" thresholds provide tage is the difficulty with elimination ors. For this band to be clinically via-
hysteresis for the signal, which can of extraneous mechanical noises. ble, the developers need to resolve
make the system more stable in the When a prosthesis strikes an object or some of the issues that led to the fail-
face of noise or conflicting inputs. rubs against something in the envi- ure of previous attempts to use
Myoelectric control of a hand or ronment, large mechanical vibrations pressure/muscle hardness transduc-
other type of prehensor is particularly can be created that may activate the ers. A key issue is inability of the sys-
applicable to transradiaJ amputation prosthesis inadvertently. Elimination tem to differentiate between actual
levels because individuals with ac- of this unwanted acoustic noise from control signals from a tendon and ex-
quired amputations usually have a the system appears to be quite chal- ternal pressures or impact from ob-
phantom sensation of the missing lenging. jects in the environment. In activities
hand. When the person with an am-
of daily living, a prosthesis wearer will
putation thinks of moving the phan- Prosthesis Control Using
tom hand, the muscles remaining in exert forces and moments on the
Muscle Bulge or Tendon socket that may actuate the pressure
the residual limb are activated natu-
Movement sensors and issue commands to the
rally. Therefore, it is possible to relate
original finger extensor muscles with Tendon or residual muscle movement drive system of the prosthesis.
opening of the prosthetic hand by has been used to actuate pneumatic In the 1970s, Otto Bock developed
placing electrodes on the skin near sensors interposed between a pros- a control system that used muscle
these muscles, for example, the exten- thetic socket and the superficial ten- hardness ·to control an electronic
sor digitorum. T he original finger dons and/or muscle. These sensors can prosthesis.23 Advantages of the system
flexor muscles can likewise be used, be used for prosthesis control. The were its immunity to electrical and
usually in conjwiction with wTist Vaduz hand, developed by a German magnetic fields, imperviousness to
flexor muscles, for the signal site to team headed by Dr. Edmund Wilms in changes in skin impedance, and free-
close the prosthetic hand. As a cofllSe- Vaduz, Liechtenstein, following World dom from a quiescent current drain.
q uence, a rather natural relationship War II, used muscle bulge to increase This system was used to provide on-
can exist between thinking about op- pneumatic pressure to operate a off and propor~onal control. Al-
erating the phantom limb and actual switch-controlled voluntary-closing though the system was commercially
operation of the hand prosthesis. In position-servo hand (ie, hand position available for several years, its use was
addition, the individual with a trans- was proportional to the amount of never widespread.
radial prosthesis is able to have pro- pneumatic pressure).
prioception from the elbow joint con- Simpson21 used muscle bulge to Implants and Neuroelectric
cerning where the prosthesis is with provide a control signal for the pro- Control
respect to the body, how fast it is portional control of an Otto Bock
The allure of neuroelectric control, in
moving through space, and what ex- gas-operated hand. The width of
opening of the hand was proportional which implanted microelectrodes in-
ternal forces are acting upon it. Con-
to the force applied by the bulge of terface directly with nerves and possi-
sequently, transradial myoelectric
the muscle. Because the bulging mus- bly with neurons, is its potential to
rial prostheses foster good control be-
cle had to exert significant pressure to provide multiple-channel control and
tto cause much of the movement and
function is somewhat natural. ensure sufficient force for control multiple-channel sensing. This is be-
[N,
valve operation, a subconscious feed- cause many motor and sensory neu-
teir
Myoacoustic Signals back path existed through the pres- rons are associated with each nerve.
.ce
))
Myoacoustic signals (auditory sounds sure sensors of the skin. This device Neuroelectric control, however, re-
~G when muscles are active) were first was a precursor to Simpson's concept mains a control possibility of the fu-
d is observed long ago but only recently of extended physiologic propriocep- ture. This method of control requires
no- have been reinvestigated in depth for tion. 7 indwelling components of some kind
1 a their potential in the control of pros- In 1999, the Rutgers University (eg, telemetry implants) because neu-
nals theses. 20 Myoacoustic control systems multifunctional hand received con- roelectric signals are generally too
has are very similar in structure to myo- siderable media attention after re- weak to be picked up on the surface of
6um electric systems. At this tin1e, there is ports of a multifunctional controller the skin.

p
182 Section 11: Th e Up per Limb
Implant Brain-machine interfaces are a injection without surgery. In addition,

variation of peripheral neural inter- the hermetically sealed capsule and
faces that use electroencephalogram electrodes necessary for long-term
signals (EEGs) for control purposes. survival in the body have already been
EEGs are electric signals that are de- approved for use in humans by the US
tected on the surface of the skull as a Food and Drug Administration in
by-product of the natural functioning functional electrical stimulation sys-
of the brain. Researchers at Duke tems. BIONs thus represent an en-
Residual \ University implanted an electrode ar- abling technology for a prosthesis con -
Prosthetic limb
hand ray into the cerebellum of a monkey; trol system based on implanted
Prosthesis Prosthesis using appropriate pattern recognition myoelectric sensors. Whereas three or
controller interface
(socket) software, the monkey controlled a re- four independent EMG sites can be lo-
mote manipulator at a distance of cated on the surface of a residual limb,
more than 1,000 km via the Inter- many more independent EMG sites
Figure 5 Planned implantable myoelec-
tric sensor system. The external coil is net. 27 One of the goals of this re- could likely be created in the same re-
laminated directly into t he prosthetic in- search was to enable patients with sidual limb using implanted sensors.
terface during socket fabrication and the quadriplegia to interact with their en- Intramuscular EMG signals from mul-
t elemetry controller is incorporat ed vironment. Wolpaw and associates 28 tiple residual m uscles offer a way to
along w ith t he prosthesis controller in provide simultaneous control of muJ-
reported on the use of an implanted
t he body of the prosthesis. Signals from
t he implants in the arm, linked through electrode array to control a robo t tiple degrees of freedom in a multi-
t he external coil, control the prosthesis arm, and Kennedy and associates 29 function prosthesis. At the very least,
via reverse telemetry. Implant power is documented the use of implanted seamless sequential control should be
supplied t hrough the external coil using cortical electrode arrays to enable pa- possible; that is, sequential control
forward telem etry. without intermediate steps such as
tients with shut-in syndrome to con-
trol a computer cursor. Reger and as- muscle cocontraction or actuation of
sociates30 demonstrated a hybrid locking mechanisms. R.E. Reilly, de-
A good deal of research concerning neurorobotic system based on two- veloper of one of the earliest implant-
prosthesis connections with nerves way communication between the able myoelectric sensor (IMES) sys-
and neurons has been conducted, 24 "26 brain of a lamprey and a small mobile tems said, "The appeal of implanted
but the practicality of human- robot. The lamprey brain was kept electrodes for EMG control seems ob-
machine intercon nections of this kind alive in vitro and was used to send vious: there is good reason to believe
is still problematic. Nervous tissue is and receive motor control and sen- that by localizing the points at which
sensitive to mechanical stresses; in ad- sory signals. This research illustrated EMG is picked up, these points can be
dition, this form of control also re- a bidirectional interface between ner- treated as relatively independent con-
trol sites. Therefore, the number of de-
quires implanted devices. Edel1 24 at- vous tissue and a machine. Although
a long way from practical application grees of freedom that can be simulta-
tempted to use nerve cuffs to generate
in prosthetics, this work reflects im- neously controlled and coordinated in
motor control signals. Kovacs and as-
portant advances in the area of an externally powered prosthesis is ex-
sociates25 tried to encourage nerve fi-
human-machine prosthesis interfaces. pected to be greater in comparison
bers to grow through arrays of holes
The development of BIONs31 (Al- with surface EMG or mechanical con-
in silicon integrated circuits that had
fred Mann Found ation, CA) for func- trol sites. Not only do superficial mus-
been coated with nerve growth factor.
tional electrical stimulation is a prom- cles become more distinguishable, but
Andrews and associates 26 reported on it becomes possible to consider using
ising new implant technology that
their progress in developing a multi- deeper muscles as additional control
may have a far more immediate effect
point microelectrode peripheral nerve on prosthesis control. These devices sites, and also control by single motor
implant. They used a 100 x 100 grid are hermetically encapsulated, leadless units." 32
array of silicon microelectrodes that electrical devices th at are small Weir and associates 33 are currently
they inserted into a peripheral nerve enough (2 mm in diameter and 15 mm involved in an effort to revisit the idea
bundle with a pulse of air. Although in length) to be injected percutane- of implantable myoelectric sensors
these authors are still working with ously into muscles. They receive for multichannel/multifunction pros-
animal models, they can identify indi- power, digital addressing, and com- thesis control. IMESs will be built that
vidual neuron action potentials and mand signals from an external trans- will be transcutaneously coupled
claim good long-term results at this mitter coil worn by the patient. The at- through a magnetic link to an exter-
point. Concerns about the pe1ma- traction of this technology for use in nal exciter/data telemetry reader. Each
nence of electrode array fixation have control of multifunctional devices is !MES will be packaged i11 a BION II
yet to be addressed. that these devices can be implanted by hermetic ceramic capsule.34 These

capsules are small enough to permit may be underutiljzed or rejected. The mercially available through Motion
injection through a 12-gauge hypo- major factor limiting tl1e develop- Control Inc. 49
dermic needle. The external exciter/ ment of more sophisticated hand/arm The Sven Hand never experienced
data telemetry reader will consist of prosilieses is the difficulty in finding widespread clinical use, even though
an antenna coil laminated into a p ros- sufficient control sources to control it was employed extensively in multi-
thetic interface so that when the pros- the many degrees of freedom required function control research using pat-
thetic socket is donned, this coil will to replace a physiologic hand and/or tern recognition of myoelectric sig-
encircle the lMES and be in an opti- arm. nals.50•51 The pattern recognition
mal geometry to inductively couple The decade fro m 1965 to 1975 was system they used was based on multi-
with these electrodes. No percutane- one of unprecedented research on the ple EMG signals, which were pro-
ous wires will cross the skin. The control of artificial limbs. T he re- cessed using adaptive-weighted fil ters.
prosthesis controller will take the out- search, particularly that cond ucted in The weighting values of these filters
put of an exciter/data telemetry Europe, was stimulated by limb ab- were adjusted to tailor the system to
reader and use tl1is output to decipher sences at birth that resulted from use the individual. Henry Lymark, direc-
user iJ1tent (Figure 5). of ilie drug Thalidomide during preg- tor of the Handikappinstitutet of
nancy. That period of activity and re- Stockholm, Sweden, later created a
simpli fied version of the Sven Hand
M ultifunctional search was also marked by excitement
called the ES Hand in an attempt to
resulting from the practical introduc-
M echanisms and tion of myoelectric control during the produce a more robust, and hence
Control mid 1960s. The Swedish Board for more clinically viable, version of the
Sven Hand. The ES Hand possessed
Many attempts have been made to de- Technical Development sponsored a
an adaptive grip and a passive two-
sign fully articulated arms and hands workshop on control of prostheses
position thumb. It was powered by a
to recreate the full function of the and orthoses in 1971, and the pro-
single motor with differential drives
hand. Taylor 35 remarked that all such ceedings of that meeting represent a
to the fingers. Unfortunately, Lymark
attempts had been complete failures. landmark publication on prostl1esis
d ied soon after the initial develop-
Myoelectric control, once consid- control research. 38 Worldwide, many
ment of this hand and the project was
ered to be the cutting edge of technol- new government initiatives were es-
never continued.
ogy, was advanced as a natural ap- tablished during this period. Develop-
Like the Sven Hand, the Philadel-
proach for the control of prostheses ments included the Edinburgh Arm, 39
phia Arm41 •42 was used in research on
because it allowed individuals with the Boston Arm, 37•40 the Philadelphia
multifunction control using weighted
amputation to use the same mental Arm, 41 .42 tl1e Wasada Hand, 43 the Bel-
filters for the pattern recognition
processes to control their prostheses grade Hand,44 ' 45 the Sven Hand,46
problem and achieved good results.
as they had used in controlling their and the Utah Arm. 47
The Belgrade Hand was likewise
physiologic limb. 36' 37 However, cur- Although many ideas were tried never used clinicaJly but has ended up
rent state-of-the-art electronic pros- and tested during this period, only a in the robotics field in the form of the
thetic hands are generally si ngle- few devices ever made it from the lab- Belgrade/USC robotic hand.52
degree-of-freedom (opening and oratory into everyday clinical prac- A more recent offering is the m ul-
closing) devices usually implemented tice. The Edinburgh Arm, which was tifunctional hand designed by Yves
with rnyoelectric control. Curren t pnewnatically powered, saw some Lozac'h. 53 This hand was a single-
prosthetic arms requiring multiple- clinical usage bu t was complex and degree-of-freedom hand (opening
degree-of-freedom control most often lacked the rob ustness necessary for and closing); however, because the
use sequential control. Locking mech- everyday use. This arm is not avail- hand had articulated fingers that
anisms and/or special switch signals able today, but it was importan t as an could move independently of each
r are used to change control from one implementation of Simpson's ideas other, it was capable of forming an
degree of freedom to another. As cur- on extended physiologic propriocep- adaptive grip for grasping objects. An
y rently implemented, sequential con- tion (EPP). The Boston Arm, devel- adaptive grip requires lower forces
a trol of multiple motions is slow; con- oped at Massachusetts Institute of than conventional prosthetic hands to
s sequently, transradial prostheses are Technology (MIT), had the first myo- hold objects because the abject to be
generally limited to just opening and electrically controlled elbow. This el- grasped can be encircled . Operating
1t closing of the hand, greatly limiting bow was extensively redesigned for under the assumption that a practical
d the function of these devices. Inclivid- commercial production.48 The cur- prosthetic hand can have only one
uals with recent hand amputations rent version is the Boston Elbow III axis of rotation for the th umb,
h expect modern hand prostheses to be (Liberating Technologies, Holliston, Lozac'h 54 performed a series of ex-
il like hands. Because these devices fail MA). The Utah Arm, which was influ- periments to determine if there was a
e to meet some users' expectations, they enced by the MIT research, is com- preferred working plane for a single-

b
•
degree-of-freedom active thumb. He output should not exceed 200 ms; ventional single-degree-of-freedom
concluded that the preferred working even this can be unacceptable for "open" or "close" EMG signal. By al-
plane of the thumb lay between 45° high-performance prosthetic compo- lowing the processor to take control,
and 55°. In our opinion, the Lozac'h nents. Based on our experience, we the mental load on the operator is re-
hand looked impressive at a demon- believe that designers should try to duced.
stration in 1992, but it did not have achieve an update rate of no more In 2002, Ajiboye and associates 64
enough torque to operate within a th an 50 ms. presented a multifunctional control-
conventio nal cosmetic glove. Although few clinically available ler based on fuzzy logic techniques
Complex time, frequency, and devices use these control approaches, with an update rate of 50 ms. T his
time-frequency identification tech- the work of Hudgins and associates 57 controller is based on three or four
niques have subsequently been used and the earlier effort of Herberts and myoelectric sites ( the maximum
to extract features from myoelectric associates62 demonstrate that some number of sites that could be isolated
signals for multifunction prosthesis form of pattern recognition of myo- wiiliout cross talk becollllng unac-
control, thanks to the advent of high- electric signals (adaptive filtering ceptable) and uses fuzzy logic tech-
speed digital electronics that can han- techniques, neural networks, genetic niques to detect EMG onset and clas-
dle algorithms of high com putational algorithms, fuzzy logic, etc) may have sify user intent. The controller is
complexity in close to real time. merit as a means of controlling multi- being developed as part of a project to
Graupe and associates 55 conducted a function devices. With a pattern rec- build a new multifunctional hand
stochastic time series analysis of EMG ognition type of controller, the user prosthesis.65 Three to four indepen-
signals. Other teams used neural net- must first train the controller to rec- dent EMG sites wiU be used to con trol
works to perform the pattern recogni- ognize specific patterns of EMG sig- three or four degrees of freedom in
tion and feature extractiou,56•58 nals. T hese EMG signals are generated the prosthetic band. Memberslup
whereas Farry and associates 59 used by the user's residual limb in response functions for each myoelectJic chan-
genetic aJgorith ms. The features de- to the user's visualization of his or her nel are based on training data, and
scribed by Hudgins and associates 5 7 phantom limb performing a specific the four sites are located with stan-
are the most widely used. They pro- function . The controller records the dard clin ical tech niques. Rules d efin -
posed extracting several parameters resulting EMG signals generated by ing the d ifferent EMG levels associ-
out of the first 200 ms of EMG and the residual musculature during the ated with a particular fu nction are
developed an approach for the classi- training trial. This training process is generated a utomatically based on the
fication of four different motions or repeated several times for each func- recorded training data.
muscle contractions. Their classification. The record ed EMGs associated Most multifunctional prosthesis
tion scheme used five different fea- with each function are then analyzed designs are doomed by practicality,
tures (mean absolute value, mean ab- offline to extract either the relevant long befo re control interface becomes
solute value slope, zero crossings, features ( using a neural network in an issue. Prosthesis users are not gen-
slope sign changes, and waveform the case of the Hudgins team 57 ) or tle with their devices; they expect
length) from several time segments of the appropriate filter weights (for the them to work in all sorts of situations
each signal. A multilayer neural net- adaptive filter of the Herberts never dreamed of by their designers.
work with back propagation classified group 62 ). The resultant feature pa- Most mechanisms fa il because of in-
myoelectric patterns using these fea- rameters or filter weights are then sufficient durabili ty, poor perfor-
tures. stored in ilie controller and used by mance, and complicated control. No
Farry and associates 58 used tl1e five the controller to recognize similar device wiU be clinically successful if it
features above as well as a few of tl1eir patterns in futw·e combinations of breaks down frequently. A multifunc-
own with genetic progranmung algo- myoelectric signals. tional design by its very nature is
rithms instead of n eural networks for Some alternatives to myoelectric more complex than a design wit h a
classification. Chan and associates60 pattern recognition, such as the sys- single degree of freedom . From a
used fuzzy logic with the Hudgins tem Kyberd and Chappell63 call "hier- maintenance standpoint, the device
group features. Engelhart's team 61 archical artificial reflexes," have been will have more components with a
combined wavelet analysis with maxi- used to automate the control process greater potential to fail. Articulated
mum likelihood estimation. The pro- in an effort to reduce the mental bur- joints on fingers are more likely to fail
cessing time required for these com- den placed on the user. Kyberd and than monocoque (solid-finger ) de-
p lex algorithms is nontrivial. Any Chappell's device is basically a multi- signs. To achieve the increased func-
delay greater than about 100 ms in ftmctional hand; however, they take tion possible with a multiple-degree-
the response of the output to a the operator out of the loop and use of-freedom hand, however, some of
change in the input is perceptible as a onboard processing and sensors in the the robustness and simplicity of a
sluggish response. Parker and Scott10 hand to tell the hand which pattern to single-degree device must be sacri-
suggest that delays between input and adopt. The operator provides a con- ficed.

Another practical consideration is niques on prosthesis control would be Angle Osteotomies

performance. The hand must be able far greater if surgeons, prosthetists, From a control standpoint, trans-
to generate enough torque a nd speed and engineers had consistently hwneral amputations follow guide-
and also have sufficient width of worked together on limb control
lines similar to those for transrad ial
opening to be useful. Many labora- problems. Surgical procedures are amputations. Elbow disarticulations
tory designs have performed well uncovered elsewhere in this book, but
conserve hwneral rotation, can be
til a cosmetic glove was added. A cos- the impact of surgical techniques, ob-
used to aid prosthesis suspension, and
metic glove is standard for prosthetic jectives, and decisions on control sites
provide a force-tolerant distal end.
hands. Unless a mechanism is de- and function is discussed in this
Long transhumeral limbs often
signed specifically for use without a chapter.
achieve good control of prosthetic el-
glove, the effect of the glove on per- bow flexion using glenohumeral flex-
formance must be taken into consid- Bones and Joints
ion. If a disarticulation is not possi-
eration. The ES Hand was designed to Preservation of joints and bone
ble, the length should usually be
work in its own cover, while the Bel- lengtl1 consistent with good medical
shortened enough to accommodate
grade Hand needed an additional practice generally leads to improved
elbow mechanisms without compro-
cover. The pinch force of a multifunc- prosthesis control. With transradial
mising function. Marquardt69 has
tional hand does not need to be as amputations, the limb should be as
used angle osteotomies of the distal
high as that of single-degree-of- long as possible. Wrist disarticula-
hwnerus to improve mechanical cou-
freedom hands because the adaptive tiops conserve natural supination-
pling between the httmerus and the
nature of the grip enables the hand to pronation of the forearm, provide
prosthesis so that humeral rotation of
encompass objects. Multifunctional contours for prosthesis suspension,
the prosthesis is readily controlled by
hands should still be capable of high and create a force-tolerant distal end
natural humeral rotation.
speeds of opening, however, and have for the lin1b. The elbow joint should
For optimu m control, the surgeon
a pinch force of at least 68 N. 66 An in- be saved whenever possible because it
should attempt to save a short lm-
depth review of the practical issues greatly enhances prosthesis control,
merus if it will be voluntarily mobile
related to the design of prosthetic just as an intact knee enhances lower
because a mobile short htuneral neck
hand and arm components was pre- limb prosthesis control. Bone length-
can be used to activate control
e pared by Weir. 67 ening might be considered for in-
switches or to push against pressure-
e creasing the length of very short
sensitive pads. Muscles attached to it
limbs when practical. If all fingers
s The Role of Surgery have been amputated, decisions about
may also be used for myoelectric con-
trol purposes. If amputation above
r, in the Creation of saving the wrist joint must be made
the elbow is pe1formed after brachia]
:s on an individual basis. Persons with
Control Sites/Sources partial hand amputations now have plexus injury, it is often helpful to
Amputation surgery plays a critical access to improved finger compo- have the flail humerus fused with the
:t
role in the clinical outcomes of pros- nents that are short enough so that scapula at the glenohumeral joint so
IS
thesis fittings and can sign ificantly af- the fitting does not make the limb too that the humeral section can be con-
s.
fect control of limb prostheses. Un- long. A functional human wrist joint trolled to some extent by action of the
l-
fortttnately, the number of surgeons is highly desirable because of its free- scapula.
r-
0 witl1 an active interest in amputation dom of movement to position an arti-
Soft-Tissue Conservation
it and amputation issues has declined ficial prehension component. fn the
appreciably, particularly compared past, fitting options were I im ited to and Reconstruction
is with the years immediately following passive/cosmetic prostheses and op- When possible, surgeons should con-
a World War II. If the control of limb position posts. Current fitting options serve residual muscles that might be
a prostheses is to advance along a broad are djscussed in chapter 14. Otto Bock used for myoelectric or other control
ce front, advancements in surgery and now has a shorter hand prosthesis; an sources. Myoplasty and/or myodesis
a surgical techniques are just as neces- even shorter partial hand mechanism procedures ensure tl1e ability to de-
!d sary as technical progress. Technolog- is tmder development through the velop tension when muscles are vohm-
iii ical advancements and surgical ad- Veterans Administration Rehabilita- tarily contracted. Myoplasty proce-
e- vancements in prosthetics should be tion Research and Development Ser- dures that connect antagonist-agonist
c- integrated, synergistic activities. Tech- vice68 of the US Department of Veter- muscle groups at the distal end of tl1e
:e- niques in orthopaedic surgery, vascu- ans Affairs. If functional wrist residual limb are often used to keep
of lar surgery, plastic surgery, and neu- movements can be conserved using the muscles in a dynamic, somewhat
a rosurgery have advanced rapidly over flexible sockets, truly exceptional natural working relationship. This can
ri- the past 30 years. Unfortunately, tl1e prostheses for this long-neglected preserve muscle tone and increase the
impact of many of the new tech- amputation level may result. potential for good two-site myoelec-

p
plasties of Sauerbruch,74 and their gain coordinated control of individu-

later modification during World War ally powered prosthetic fingers in the
II by Lebsche.75 The surgical proce- future. We recently reported the fit-
dure to create a Vanghetti- ting of a proof-of-concept prosthesis
Sauerbruch-Lebsche muscle tunnel using tendon exteriorization cineplas-
cineplasty was most recently described ties as control inputs to powered
by Bruckner. 76 prosthesis controllers.84
This control technique was revived Surgical creation of several new
in Europe in the 1980s.76-78 Bruckner miniature tunnel cineplasty control
and Thomas 79 documented their ex- sources on the torso may be particu-
periences with the functional value of larly desirable for individuals with
the Sauerbruch-Lebsche procedure. high-level bilateral limb loss who
They created a total of 20 tunnels in need multifunctional control yet have
16 patients over a period starting in limited control sites. Marquardt85 de-
1988; all but one of these tunnels scribed the use of a pectoral cine-
were considered successful. They plasty to actuate a three-position pull
noted that the functional o utcome switch to provide sequential switch
(use of the prosthesis), however, de- control of an electromechanical hand
pended on the motivation and mental and wrist rotator. Direct muscle con-
well-being of the patient. Others trol through tunnel cineplasties is
agreed that this was critical to the particularly attractive because of the
Figure 6 Forearm muscle tunnel cine-
success of the procedure.80·81 With proprioception tl1ey naturally provide
plasty in the German style of prosthesis. the exception of Bri.ickner and Tho- to the user. This feature accomplishes
These were seldom used in the United mas79 and Beasley,70 few surgeons one of tl1e key goals of limb prosthe-
States because of the limited force and since Sauerbruch and lebsche have sis control, obtaining good control of
excursion available from forearm mus- systematically examined new ways to multiple prosthetic functions without
cles.
externalize the force of muscles for too much mental exertion given over
tric control from these muscles. In my- control. A muscle tunnel cineplasty is to the control process by the user.
odesis, the residual muscle is stitched shown in Figure 6. Powered prostheses make the use of
to the bone. Single muscles that may Although tunnel cineplasties have tunnel cineplasty control sources pos-
have no functional purpose after am- been rare in the United States since sible even when tl1ey can develop only
putation yet can be voluntarily acti- the 1970s, they offer a unique way for small forces or excursions. The com-
vated should be attached to a reactio11 surgeons to create control sources. bination of powered prostheses and
point and saved for possible use as a New surgical techniques and the wide electronic position control systems, in
myoelectric control site. Preservation availability of powered prostheses conjunction with new surgical tech-
of muscle tone, length, and excursion may lead to a revival of this proce- niques and procedures such as multi-
are of paramount importance for the dure. Leal and ~alone82 successfully ple miniature tunnel cineplasties, may
success of future surgical procedures fitted a person with a transradial am- open up a new era of control based
in creating novel physical muscle- putation who had a standard biceps on tl1e older yet still vital ideas of
prosthesis interfaces. Myoplasty could tunnel cineplasty with an electric muscle cineplasty.
be performed on the superficial resid- hand that was switch-controlled from Adherence of the skin to underly-
ual muscles, and myodesis could be the cineplasty site. Lticke and associ- ing muscle is a less direct method of
used on the deep residual muscles. ates83 discussed the use of cineplasty using a muscle as a control source.
in connection with modern electronic Skin adherence generates skin motion
Cineplasty prosthesis technology. Beasley's 70 ten- when muscle contraction causes
Surgical procedures such as the don ex1:eriorization cineplasty proce- movement. This method of control
Vanghetti-Sauerbruch-lebsche mus- dure shows promise. Tendon exterior- was presented by Seamone and asso-
cle tunnel cineplasty or the tendon ex- ization does not traumatize the ciates.86
teriorization cineplasty,70 which exter- muscle itself and therefore is thought Other surgical reconstructions in-
nalize the force and excursion of a to have minimal influence on a mus- corporate phalangization of the re-
muscle or tendon, can provide good cle's circulation and neurologic mech- maining bones, such as those of the
control interfaces. The Vanghetti- anisms. This procedure illustrates the forearm in the Krukenberg proce-
Sauerbruch-Lebsche muscle tunnel potential for surgical creation of sev- dure.87 The Krukenberg method orig-
cineplasty is an evolution of the ten- eral such control sources on the fore- inated in Germany in 1917 and re-
don "loops" and "clubs" of arm; these could enable individuals ceived much impetus in Germany and
Vanghetti, 71 -73 the muscle tunnel cine- with a long transradial amputation to Russia throughout World War II.

Swanson and Swanson 88 explained Ulnar nerve

the use of the Krukenberg procedure
in children; Mathur and associates 89
documented experiences with the
procedure in India; and Baumgartner
and Asey90 of Germany presented an
overview of 19 individuals with bilat-
eral amputations who had Kruken-
berg hands for an average of 45 years.
Although excellent functional results
can be obtained with this procedure,
it is not widely used because of poor Servocontroller
cosmesis.
The Krukenberg procedure re- Figure 8 Neuromuscular reorganization.
Diagram illustrates how reinnervation of
mains a viable method to enable
the pectoralis muscle with the maj or
direct prehension control. Older sur- nerves of the arm might be used to cre-
gical procedures such as the Kruken- ate physiologically correct myoelectric
berg procedure can effectively com- control sites for prosthetic arm control.
plement modern surgical procedures.
The patient in Figure 7 had a modern
toe transplant procedure on the right
Figure 7 An older surgical procedure and forearm. After reinnervation, the
side and a Krukenberg procedure on (Krukenberg) complements a modern sur-
the left. Because the patient was blind, muscle may be a good source of mul-
gical procedure (toe transplant) to re-
retention of tactile sensation for in- store f unction to a bNnd patient. The toe tiple myoelectric sites or provide
teraction with the environment was transplant to the right arm restored fine other kinds of input for prosthesis
grasping fu nction to the right side, while control. The primary advantage of a
of primary importance. A Krukenberg surgical revision of the left arm to enable nerve-graft system is the potential for
procedure can also be used for con- the radius and ulna to be used as large
a greater number of discrete control
trol of powered transradial prosthe- fingers (Krukenberg procedure) restored
gross prehensile ability to t he left side. In signals that relate directly to the orig-
ses. Some users choose to use their
both instances, tactile sensation is pre- inal function of the limb. In the case
Krukenberg limbs in the privacy of
served. Preservation of tactile sensation is of the person with a high-level ampu-
their homes because of the exceUent of particular importance for the restora- tation, the median, ub1ar, radial, and
sensory and motor qualities, but pre- tion of function in blind individuals. Both
musculocutaneous nerves are usually
fer to use prostheses over their arms procedures were performed in 1995 by a
hand surgeon at Northwestern Memorial still present. The musculocutaneous
when they are in public venues. Al-
Hospital in Chicago, Illinois. nerve controls elbow flexion, while
though this procedure has been used the radial nerve controls extension.
primarily with blind individuals with Pronation of the forearm is directed
y
bilateral hand amputations, the pro- by the median nerve, and supination
i
,f cedure may have application for nerves of the amputated limb. The is directed by the radial and musculo-
sighted individuals and individuals potential to tap into these lost control cutaneous nerves. Extension of the
with unilateral amputations in certain ' signals may be realized usirlg nerve- hand is governed by the radial nerve,
,f circumstances.91 Activation of pres- muscle grafts. As first suggested by and flexion by the median and ulnar
sure-sensitive transducers by the Hoffer and Loeb,92 it may be possible nerves. Because each of these nerves
Krukenberg limb is one application to denervate expendable regions of innervate muscles that control the
n
for control of a hand; myoelectric muscle in or near an amputated limb motion about different degrees of
!S
control is another option. and graft the residual peripheral freedom, they should theoretically
)- nerve stumps to these muscles. The supply at least four independent con-
Neuromuscular trol signals. The nerves would be con-
peripheral nerves would then reinner-
l-
Reorganization vate the muscles and these nerve- trolling functions in the prosthesis
Kuiken and associates 2 suggest a muscle grafts would provide addi- that were directly related to their nor-
promising new surgical technique, the tional control signals for an externally mal anatomic function. Furthermore,
e- use of neuromuscular reorganization powered prosthesis (Figure 8). existing myoelectric technologies
~- to improve the control of artificial T he concept is to denervate a mus- could be applied to make the addi-
e- arms. Although the limb is lost in an cle that is not functionally critical and tional control signals accessible with-
id amputation, the control signals to the reinnervate it at multiple places with out the use of implanted nerve cuffs,
[I. limb remain in the residual peripheral nerves that formerly went to the band implanted transmitter- receiver sys-

terns, or percutaneous devices. lMESs titanium abutment that protrudes feelings and desires may take time to
placed at the time of initial surgery through the skin from the cut end of mature and to emerge. An amputation
might complement this procedure the bone. Branemark's techn.iques ap- often leads to job changes and oilier
nicely. Another advantage is that the pear to have greatly diminished the changes that require time to be sorted
shoulder would be free to control infection problem that persisted in out. The prosthesis exists amid many
other functions , such as an artificial earlier efforts.95 Direct extensions of life changes and this makes the initial
shoulder. This new approach has been fmgers or thumb bones are good ex- prescription difficult. Accordingly, di-
successfully applied in one patient amples of EPP. Should direct skeletal agnostic and temporary prostheses
with bilateral, high-level amputations attachment prove viable, it could rev- can be very useful for early fittings.
to control a shoulder disarticulation olutionize the prosthetic fitting of
prosthesis. Each of the residual bra- some amputation levels. The prosthe- Unilateral Transradial
chia! plexus nerves was grafted to a sis of the future might be a multi- Prostheses
different region of deinnervated pec- functional device that is mounted Transradial prostheses may be con-
toralis muscle. Kuiken and associates2 into the skeleton using osseointegra- trolled successfully in several ways.
are presently considering using th is tion and controlled with neuromus- Cable-controlled voluntary-opening
technique with w1ilateral amputa- cular reorganized multiple miniature and voluntary-closing prehensors
tions at the transhumeral level, graft- muscle cineplasties. (nonanthropomorphic) work well
ing nerves to different regions of
with individuals witli transradial am-
deinnervated biceps brachii .
Instead of myoelectric sites, minia- Control of Prostheses putations, although cable-controlled
mechanical hands are generally ineffi-
ture tunnel cineplasties could be cre- for Unilateral Limb cient. When myoelectric control fast
ated in the reinnervated muscle. In Loss became available, it was thought to
conjunction with miniature tunnel
Although fittings of individuals with have more important applications for
cineplasties, the work of Kuiken's
unilateral amputations are technically higher level amputations than transra-
group 2 presents interesting possibili-
much simpler than bilateral fittings, dial amputations. However, myoelec-
ties for future long-term research.
many individuals with wiilatera1 limb tric control has performed admirably
They demonstrated tliat a section of
muscle could be denervated and then loss do not wear the prosthesis, partic- at this level; in fact, its application for
ularly those with transhumeral and the person with a trnnsradial amputa-
hyperreinnervated with a different
nerve. Thus, it might be possible to higher level limb loss. The person with tion is the most common (Figure 4).
reinnervate a piece of previously den- a unilateral amputation has a physio- Use of two myoelectric sites is pre-
ervated sound muscle with a rerouted logic arm and hand that can accom- ferred to control the two functions
nerve from the residual limb. A min- plish most tasks. Therefore, the pros- (closing/opening) of the hand because
iature tunnel cineplasty performed on thesis at best serves only in an assistive this gives the operator direct control of
this newly reinnervated muscle could mode. Some individuals with an am- each function. This kind of control
create a source of prosthesis control. putation may want a prosthesis pri- can become subconscious in nature
In theory, the amputee would not marily for appearance. Some may infor some individuals. The prehensor
need to relearn how to control the corporate it extensively into their can be various electronic hands or
reinnervated muscle; physiologically activities and body image, while oth- other nonanthropomorphic electronic
correct control could be maintained ers may use it only for specific func- prehensors.
and sensory feedback would be avail- tions (such as work or sport activi- Single-site, two-function control is
able through the cineplasty. ties). Many individuals with uniJateral quite acceptable for individuals with
amputations decide not to wear a an amputation who do not have two
Osseointegration prosthesis. Professionals associated good myoelectric sites. It has been
Another surgical intervention is the with prosthesis fittings need to sup- used effectively with both children, in
pioneering work in the area of direct port the patients' decisions about us- the New Brunswick system, and
skeletal attachment (osseointegra- ing prostlieses. Nonetheless, they must adults. Combination of the single-site,
tion) conducted by Branemark93 and also inform tlie patient about what single-function myocontroller of hand
his associates 94 in Sweden, which is kind of fitting might best serve his or opening witli automatic-powered
described in more detail in chapter her goals. Prosthetic fitting of individ- closing (the St. Anthony control cir-
54. These orthopaed ic surgeons and uals with an upper limb amputation is cuit, or "cookie crusher" system) has
engineers have created interfaces for partially an iterative process because been effective with very young chil-
direct skeletal attachment systems for these individuals cannot know what dren born with limb absences.
upper and lower limb amputations. problems they will face until they ac- A pair of single-site, two-fw1ction
With osseointegration, a prosthesis is tually use a prosthesis in their natural controllers can be used to control
attached directly to the skeleton via a environment. In addition, their true four functions of powered hand

opening/closing and powered pro- hensor during forearm lifting against

nation/supination by the person with a load is avoided, which is a problem
a short transraclial amputation. In with a cable-operated elbow if the ca-
general, supination/pronation is not ble is also used to operate a
necessary for most individuals with a voluntary-opening (spring-return)
unilateral amputation unless a partic- prehensor. We believe that myoelec-
ular vocation or hobby demands it. tric control of prehension, in this case
Powered supination/pronation adds from the biceps and triceps, is some-
weight distally and also adds com- what natural because gripping objects
plexity. Sockets and apparatus that al- strongly often involves contraction of
low natural supination/pronation muscles quite distant from the hand.
Figure 9 Hybrid unilateral transhumeral
powered by residual movements of The relationship between prehension
fitting consisting of a body-powered el·
the amputated limb are recom- and muscle contraction has been bow and myoelectrically controlled hand.
mended whenever possible. called the myoprehension concept.98 The elbow is controlled in the usual fash-
Sears and Shaperman 96 demon- RSL Steeper (London, England) ion by glenohumeral flexion assisted by a
offers a body-powered elbow that is counterbalancing elbow (Otto Bock Auto·
strated the effectiveness of propor- matic Forearm Balance [AFB) Elbow, Otto
tional control in 1991. However, if designed for a hybrid control ap-
Bock). This type of elbow is used because
powered prostheses have slow dy- proach to transhumeral fittings. The myoelectric hands tend to be heavy. The
namic responses (ie, hands open or elbow encompasses an electrical myoelectric hand is closed by activation of
close at slow rates), then proportional switch that is connected with the el- the biceps brachii and opened by action of
bow locking mechanism. When the the triceps.
control is not necessary for effective
control; on-off control is sufficlient. elbow is unlocked, t he electrical
Rapidly moving prostheses with max- switch is open; when locked, the
imum angular velocities greater than switch is closed. This allows a single cause the cable is connected di1·ectly
2.0 to 3.0 rad/s (-115°/s to 172°/s) re-
cable to operate their servo- to the output position of the elbow,
controlled hand, and also the elbow, the position of the body cannot get
quire proportional control.
without interaction. When the cable ahead of the corresponding position
r
Control of Unilateral is pulled to operate the unlocked el- of the elbow and forearm . This kind
Transhumeral Prostheses bow, the electrical connection to the of controller is similar in operation to
hand is turned off. When the elbow is automobile power steering. The ap-
As with transradial prostheses, traos- locked, the connection to the hand is proach is based on Simpson's princi-
humeral prostheses can function well on; puJling on the cable operates the ples of EPP.7 Heckathorne and associ-
with totally cable-operated body- hand through the position servo- ates99 have reported on this technique
powered prostheses when relatively control system. Another way to use for a clinical fitting. The advantages
long limbs remain. Several other ap- this elbow design is to place a two- are that proprioception is maintained
e proaches are common. position switch in series with the ca- even while using a powered elbow,
,r For individuals with a trans- ble that controls the elbow. When the and the force and excursion necessary
,r humeral amputation with long resid- elbow is unlocked, cable operation is to operate the elbow can be matched
.C ual limbs, the hybrid approach of a normal. When the elbow is locked, to the user's force and excursion capa-
cable-operated, body-powered elbow pulling the cable lightly will activate bilities. This partkuJar control ap-
is combined with myoelectric control the first position of the switch and proach has been described in detail by
h from the biceps (closing) and triceps close the hand. Pulling the cable with Doubler and Childress 100•10 t and is
0 (opening) of a powered prehemsor greater force will activate the second reviewed in some depth by Weir. 102
n (hand or nonhand) is a very func- position on the switch and open the If individuals with transhumeral
n tional fitting approach. This approach hand. In both cases, the concept is to amputations cannot operate a body-
d has been used effectively in Europe reduce the number of control sources powered elbow well for reasons such
e, for more than 30 years. Billock97 has needed. However, simultaneous con- as cliffiClllty with the locking and un-
.d used this technique effectively with trol of both functions is impossible locking function, a powered elbow
d many people. It is a relatively simple with this control approach. can be used. The elbow is often myo-
r- approach, technically comparable to a An alternate but similar approach electrically controlled, with flexion by
1s transradial myoelectric fitting (Figure is to use a powered elbow instead of the biceps and extension by the tri-
1- 9). The hybrid control/power ap- the body-powered elbow yet control it ceps. The prehensor can be cable-
proach has reasonable proprioceptive in a similar fashion, using the cable to controlled and body-powered. This
,n qualities and allows simuJtaneous co- operate a position servomechanism can be an effective prosthesis in a
ol ordinated control of elbow and pre- controlling the elbow. This approach work environment if a total cable-
1d hensor function. Opening of the pre- is a type of boosted cable control. Be- driven system cannot be used. This

•
Unilateral Shoulder pronation-supination remaining, on
Disarticulation Prostheses both sides. Although bilateral pow-
ered hands and myoelectric control
Individuals with unilateral shou lder are often used, we believe that these
disarticulation often choose not to individuals frequently benefit from at
wear prostheses. Some prefer to wear a least one cable-controlled hook-like
lightweight passive prosthesis that prosthesis. Passive (friction or lock-
swings comfortably during walking ing) wrist flexion will be useful, at
and can be positioned for placement least on the dominant side. Conven-
of the cosmetic hand in their lap when tional cable-controlled hooks on both
they sit. Light, passive grasp by the sides are also very functional; this ap-
cosmetic hand may provide some util- proach provides the precision capa-
ity. Body-powered prostheses are mar- bilities of hook prehensors along with
ginally effective at this level of ampu- good proprioception from the cable-
tation, when the contralateral limb is operatcd control systems and the long
Figure 10 Myoelectrically controlled Utah fu lly functional. The user often has residual limbs. The option finally se-
Arm (Motion Control Inc). Elbow flexion somewhat limited force and excursion, lected will be highly dependent on the
and extension are controlled proportion- compared with the person with a mid- needs and preferences of the user.
ally by myoelectric signals from the bi- to long transhumeral amputation, and
ceps brachii and the triceps, a natural Powered hand prostheses may be used
kind of elbow control. After the forearm
a body-powered system may be diffi- bilaterally for aesthetic concerns;
remains in one position for a set period cult to operate. A powered prosthesis however, there are functional disad-
of time. the elbow locks mechanically (eg, electric elbow with electric hand vantages. Hands are usually limited to
and control is transferred automatically or other powered prehensor) may also one prehension pattern (palmar pre-
to the hand (myoprehension). A rapid co-
be undesirable at this level of amputa- hension), and their bulk adds djffi-
contraction of both muscles is used to
transfer control back to the elbow. (Pho- tion because of the marginal func- culty in constricted spaces and often
tograph courtesy of Motion Control, Salt tional gains when the opposite limb is blocks sightlines to objects.
Lake City, Utah.) fully capable. Powered limbs also add
weight, a negative facto r in this kind of Bilateral Transradial
fitting. Amputations With One
approach has been promoted for use Long Limb and One Short
with the electronic elbow from Liber-
Control of Prostheses Limb
ating Technologies.
For individuals with transhumeral for Bilateral Limb Individuals with one long limb and
one short limb may be fitted with ca-
amputations who do not want to use Loss ble control or myoelectric control on
the harness of cable co ntrol or cannot
Fitting problems become dramatically both sides. Hybrid control may be
tolerate a harness (because of skin different when both arms are missing. useful; the long (dominant) side can
grafts, for example), or for individuals Because of the numerous combina- be provided a cable-controlled hook
with a relatively short limb (weak gle- tions of bilateral limb loss that exist with wrist flexion and the short side
nohumcral leverage), the controls can when amputation level, long versus fitted with a myoelectrically con-
be completely myoelectric. A two-site short variations, associated move- trolled hand (perhaps with an electric
myoelectric control system that can be ment limitations, and pathologies of wrist rotator). A wide range of fitting
used to control the elbow proportion- limb segments are considered, only a possibilities is possible. A completely
ally in a Utah Arm is shown in Figure few conditions will be addressed in cable-co ntrolled system with hooks
10. If the elbow is held stationary for a this section. The focus is on general also can be very effective, as demon-
short period of time, the elbow auto- principles for the fittings rather than strated by so many individuals with
matically locks and this action trans- specific details. an amputation who have developed
fers the myoelectric proportional con- exceptional arm/prehensor skills.
trol to the hand. A quick co- Bilateral Long Transradial
contraction of the biceps and triceps Amputations Transhumeral and
muscles is used lo transfer control Individuals with long bilateral limb Transradial Amputations
back to the elbow. This is a form of loss can effectively control a wide Individuals with both transhumeral
two-site, four-function control in range of prostheses, from cable- and transradial amputations also can
which all functions are not directly ac- controlled voluntary-opening hooks be fitted well with body-powered,
cessible. Control can be alternated be- to bilateral myoelectric hands. A key cable-controlled systems. The func-
tween the hand and the elbow. goal is to preserve the physiologic tional dexterity that many of these in-

Figure 11 An individual with bilateral

(
transhumeral amputations f itted with a
,1\ \
)
body-powered system on t he right side
with single-cable, four-function control
through which he can control th e elbow,
wrist flexion, w rist rotation, and prehen-
sion. The left side is fitt ed with a body-
powered elbow; single-site, two-f unction
myoelectric control of the Otto Bock Gre- .P
d
,.
ifer prehensor (Otto Bock) from t he bi-
~
ceps brachii; and a passive w rist rotator
that can be rotated by rub bing t he crepe
0
rubber band encircling it against the B
body.
Figure 12 Man with bilateral shoulder disarticulations w ho has been f itted with pros-
theses on both sides. A, The rig ht side is fitted w it h a single-cable, four-f unction, body-
powered system and Liberty-Collier locking shoulder joint (Liberating Technologies Inc).
dividuals develop with this kind of
Chin levers are used to lock and unlock t he shoulder, elbow, and wrist rotator. A lever
control is extraordinary. The transra- on t he wrist unlocks and locks the w rist f lexion unit. B, Th e left side is fitted w ith a
dial side is normally considered the Liberty-Collier locking shoulder joint, powered elbow (Liberty Mutual), powered wrist
dominant side for fitting. If the trans- rotator (Otto Bock), and powered prehensor (Otto Bock Greifer; Otto Bock). A mechan-
Ld
ical chin lever is used to lock and unlock t he shoulder. Chin movement against rocker
a- humeral amputation is reasonably
switches controls t he elbow, wrist, and prehensor. The two arm system s are mechanically
m long, cable control can be used on the decoupled because one is entirely body-powered and the other is entirely electronic, ex-
)e transradial side with a cable- cept for the passive joints. The body-powered prosthesis is used as the dominant arm,
m controlJed, body-powered elbow on wit h t he electronic limb assisting. These prostheses enable this individual to be highly
)k the transhumeral side, in conjw1ction functiona l.
de with myoelectric control of an elec-

n- tronic prehensor. \i\Then the trans-
possibly the side of original hand cable can be used to flex the elbow,
ric humeral amputation is short, a pow-
dominance if the residual limb is long open the terminal device, rotate the
ng ered elbow should be considered.
enough. Single-cable control of four wrist, and flex the wrist. Controls are
~ly
,ks body-powered functions has been added to lock and unlock the wrist
Bilateral Transhumeral found to be very fw1ctional. This is a rotator, the wrist flexor, and the el-
,n-
Amputations technique pioneered by George Rob- bow, which allows the limb to be rigid
ith
,ed Individuals with bilateral trans- inson at Robin Aids Prosthetics or free. This four-function mecha-
humeral amputations frequently use (Vallejo, CA) and applied there by nism is described in greater detail by
external power on one side or the James Caywood. Their system has Heckathorne and associates. 10 4
other, but totally body-powered, been redesigned so that its fabrication A body-powered elbow and myo-
cable-controlled systems can be func- is more modular and easier to ap- electrically controlled prehensor can
:ral tional at this level. We believe these ply. L03 The single-cable, four-function be fitted to the nondorojnant side if
can individuals should be fitted with a control approach allows a person with the residual limb is fairly long. An
:ed, body-powered, cable-controlled sys- bilateral transhumeral amputations to electric elbow may be useful if the
nc- tem on one side-usually the side independently position joints of the limb is short, using myoelectric or
in- with the longest residual limb but arm and lock them into position. One rocker-switch control (Figure 11).

F
Short Transhumeral and the torso is brought back to vertical muscle. Brain Res 1995;676:113-
Bilateral Shoulder (Figure 12). 123.
Disarticulation 3. Abul-Haj CJ, Hogan N: Functional

assessment of control systems for cy-
Amputations Summary bernetic elbow prostheses. Part I: De-
BiJateral shoulder disarticulations are The loss of a hand or arm is a major scription of tJ1e technique. IEEE Trans
handled like the transhumeral ampu- disability. Unfortunately, today's pros- Biomed Eng l990;37:1025 - 1036.
tations. We use a fow·-function body- thetic components and interface tech- 4. Abul-Haj CJ, Hogan N: Funcfonal
powered cable-controlled system on assessment of control systems for cy-
niques are still a long way from realiz-
the dominant side (Figure 12). The bernetic elbow prostheses. Part TJ: Ap-
ing fully functioning artificial arm or
plication of the technique. IEEE Trans
nondominant side is fitted with a hand replacements with physiologic Biomed Eng l990;37:1037- 1047.
powered elbow, a powered prehensor, speeds of response and strength that
5. Michael JW: Upper limb powered
and a powered wrist rotator. The can be controlled almost without components and controls: Current
wrist rotator and the powered pre- thought. Heckathorne (personal com- concepts. Clin Prosthet Orthot 1986;10:
hensor are controlled by chin move- munication, 2003) believes the per- 66-77.
ment against rocker switches. The el- ception of prosthetics research is not 6. Bernstein N: The Co-ordi~ation and
bow is controlled by a two-position like that of research in the physical sci- Regulation of Movements, London, En-
pull switch that is activated by shoul- ences. In the physical sciences, the goal gland, Pergamon Press, 1967.
der elevation. Heckathorne and asso- is generally abstract and the details are 7. Simpson DC: The choice of control
ciates1 described the complementary obscure to the layperson. In prosthet- system for the multi movement pros-
function of bilateral hybrid prosthe- ics research, every person with a trau- thesis: Extended physiological proprio-
ses of this type. The user can don and matic amputation or unilateral conception, in Herberts P, Kadefors R,
doff the prostheses independently, genital limb deficiency knows the goal Magnusson RI, Petersen I (eds): The
and he uses them effectively in activi- on a very personal level. Every ad- Control of Upper-Extremity Prostheses
ties of daily living. Nevertheless, mod- vancement in limb prosthetics is com- and Orthoses. Springfield, IL, Charles
ification of the home environment pared to recreation of the physiologic C Thomas Publishers, 1974, pp 146-
150.
was necessary to simplify function. limb and the experience with the arti-
Use of a totally body-powered sys- ficial limb. Although many people use 8. Childress DS: Powered limb prosthe-
ses: Their clinical significance. IEEE
tem on one side and an electric sys- prostheses and thus appear to accept
Trans Biomed Eng 1973;20:200-207.
tem on the other allows the two sys- the state of the art, they are generally
9. Farrell T: The Effect of Non-Linearities
tems to be effectively decoupled from not satisfied with it. Prosthetics re-
on Extended Physiological Propriocep-
a control standpoint. Forces and mo- search is driven by dissatisfaction. tion (EPP) Control ofa Powered Pros-
tions to activate the body-powered thesis. Evans ton, fL, Northwestern
side do not activate the electric sys-
tem on the opposite side. Likewise,
Acknowledgments University, 2003. Thesis.
10. Parker PA, Scott RN: Myoelectric con-
operation of the electric prosthesis We thank the Veterans Administra- trol of prostheses. Crit Rev Biomed Eng
does not activate the body-controlled tion Rehabilitation Research and De- 1986;13:283-310.
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1984.
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Ci1]eplasty, an end-result study./ Bone Society for Prosthetics and Orthotics
sis of extended physiological propri-
Joint Surg Am l 957;39:59-76. (ISPO). Chicago, IL, 1992, p 205.
oception as a control technique.
91. Ryder RA: Occupational therapy for a
82. Leal JM, Malone JM: VA/USMC elec- / Rehabil Res Dev 1984;2 l:5-J 8.
patient with a bilateral Krukenberg
tric hand with below elbow cineplasty. 101. Doubler JA, Child ress DS: Design
amputation. Am I Occup Ther 1989;43:
Bull Prosthet Res 1981; 10:52-56. and evaluation of a prosthesis con-
689-691.
83. Liicke R, Marquardt E, Carstens C: trol system based on the concept of
92. Hoffer JA, Loeb GE: Implantable elec-
Abstract: Kineplasty accordiJ1g to extended physio logical propriocep-
trica l and mechanical interfaces with
Sauerbruch: The fresh indication for nerve and muscle. Ann Biomed Eng tion./ Rehabil Res Dev 1984;21:19-31.
the pectoralis canal in amputations in 1980;8:351 -360. 102. Weir RF ff Direct Muscle Attachment
,. the region of the shoulder girdle. Pro- 93. Branemark PI: Osseoiotegration: Bio- as a Control Input for a Position Servo
ceedings of the Sixth World Congress of teclmological perspective and clinical Prosthesis Controller. Evanston, IL,
the International Society for Prosthetics modality, in Branemark Pl, Rydevik Northwestern University, 1995. Dis-
ii and Orthotics (ISPO), November 12-17, BL, Skalak R (eds): Osseointegration in sertation.
:t 1989. Copenhagen, Denmark, ISPO Skeletal Reconstrucl'ion and Joint Re- 103. Childress DS, Krick H, Heckathorne
Publications, Kobe, Japan, p 200. placement. Chicago, IL, Quintessence CW, Uellendahl J: Positive-locking
Publishing Co Inc, 1997, pp 1-24. components and hybrid fitting con-
84. Weir RF, Heckathorne CW, Childress
DS: Cineplasty as a control input for 94. Branemark R, Brilnemark Pl, Rydevik cepts for persons with high level bi-
B, Myers RR: Osseointegration in skel- lateral arm amputations. Proceedings
externally powered prosthetic compo-
etal reconstruction and rehabllitation: of the l 2'h Annual Conference on Reha-
nents. ! Rehabil Res Dev 2001;38:357-
A review./ Rehabil Res Dev 2001;38: bilitation Engineering Technology (RE-
363.
175-182. SNA), New Orleans, LA 1989, pp
85. Marquardt E: Come-back of the pec- 95. Hall CW, Rostoker W: Permanently 296-297.
toral cineplasty. / Assoc Child Prosthet attached artificial limbs. Bull Prosthet I 04. Heckathorne CW, Duff S, Uellendabl
Ortlzot Clin 1987;22:32. Res 1980;10:98-100. J, Childress D: The trans-humeral
j 86. Seamone W, Schmeisser G, Hoshall H: 96. Sears HH, Shaperman J: Proportional four-function forearm set-up. Pro-
A powered cable drive for prosthetic- myoelectric band control: An evalua- ceedings ofthe Ninth World Congress of
orthotic systems, in Gavrilov M, Wil- tion. Am I Phys Med Rehabi/ 1991;70: the International Society for Prosthetics
son AB Jr (eds): Proceedings of the 20-28.
and Orthotics, Amsterdam, The Neth-
Fourth International Symposium on 97. Billock J: Upper Limb prosthetic man- erlands, furze 28-July 3, 1998. Co pen-
Advances in External Control of Human agement: Hybrid design approaches. hagen, Denmark, ISPO Publications,
16. Extremities. Dubrovnik, Yugoslavia, Clin Prosthet Orthot l 985;9:23-25. 1998, pp 601-603.
Yugoslav Committee for Electronics 98. Child ress DS: Biological mechanisms
ar-
and Automation, 1973, pp 736-755. as potential sou rces of feedback and
,ro-
1-
h-

Partial Hand Amputation:
Surgical Management
E. Ouellette, MD, MBA
Int roduction
The primary goals of amputation sur- A number of standard tests are surements are also most accurate
gery are preservation of length and now used to evaluate the musculo- when three trials are averaged.
useful sensibility, prevention of symp- skeletal components, sensation, and Evaluating tactile sensitivity
tomatic neuromas and adjacent joint functional capacity of the hand. The includes assessing discrimination
contracture, early prosthetic fitting musculoskeletal assessments include thresholds for pressure, temperature,
where applicable, and prompt return measurement of muscle strength and vibration, and two-point discrimina-
of the patient to work or play. 1 When joint range of motion, and sensory tion.21'22 Normal, static two-point dis-
the amputation is for a malignant tu- function is evaluated through tactile crimination at the fingertips is ap-
mor, the primary goal is to restore the sensitivity.9 • 11 Functional capacity is proximately 6 mm. 11 •23 Moving two-
best function possible while preserv- determined by direct observation of a point discrimination can also be used
ing life. Evidence exists that after am- patient's ability to manipulate objects to test the mechanoreceptors in the
putation of a limb, the brain reorga- and otherwise use the band. 12 • 14 How hand. 24 •25 Normal values for moving
nizes in both the motor and sensory to assess functional impairment re- two-point discrimination are slightly
cortices.2 The opposite motor and sulting from lost range of motion is lower (4 mm) than those fo r static
sensory cortices increase activity. This well outlined in several sources, in- two-point discrimination measured in
plasticity has been demonstrated in cluding the American Medical Associ- the same person.
both animals and humans by moni- ation's Guides to the Evaluation of Per- Pressure sensitivity can be evalu-
toring activity via transcranial mag- manent Impairment. 7 •15• 17 ated by Semmes-Weinstein monofila-
netic stimulation. In Macaque mon- Prehensile ac6vities involve power ments,26 which are a series of nylon
keys, the somatotopic map for the and' precision grips and are evaluated filaments of decreasing diameters
residuum of a finger that has been by grip strength measurement and, in such that the force required to bend
amputated occupies the same area the case of precision grips, by a move- each filament after skin contact is less
that once represented the entire fin- ment profile as well. 18 ' 19 The hand for each successive filament. These are
ger.3 Th is plastic adaptation of the dynamometer provides the most con- applied in succession until the patient
brain may provide opportunities to sistent measure of power grip is unable to feel the pressure. Pressure
enhance the amputee's rehabilitation. strength, assessed by averaging three sensitivity does not correlate with
separate trials. 20 Three types of preci- two-point discrimination.
sion grip involve the thwnb and in- Point localization, tactile object
Hand Function dex and middle fingers: tip pinch, recognition, and sudomotor function
The primary objective of hand surgery three-jaw chuck pinch, and lateral are also important in evaluating sen-
is to restore function to an injured pinch. Tip pinch between the thumb sory deficits. Point localization is
hand, so the surgeon should under- and the index finger is used to pick up tested by touching the skin with a
stand basic hand function and how to objects such as paper clips; the three- probe in one or two separate loca·
evaluate it before undertaking repair jaw chuck pinch uses all three digits tions and asking the patient to iden·
or reconstruction. The method of to grasp objects more firmly; and lat- tify those locations. 15 ' 27 Tactile object
evaluating function must adequately eral pinch, which, like tip pinch, is be- recognition, also known as tactile
assess the extent of the injury and pre- tween the thumb and the index finger, gnosis or stereognosis, is the ability to
dict the outcome of reconstruction. 4 • 8 is used to bold a key. These grip mea- recognize an object placed in the

an industrial worker, usually working and venous anastomosis, to use

Zone with a circular saw, accidentally am- K-wires for bone fixation, and to su-
Sterile
DP-I
matrix putates the finger at the midnail area. ture the digital nerves bilaterally.31 A
Children sustain fingertip amputa- free vascularized nail graft from the
DP-IIA
tions when a door is forcefully toe to the fmgertip can provide satis-
DP-IIB slammed on the digit. The treatment factory functional as well as aesthetic
Germinal depends on whether the clean, ampu- results. By transferring an osteoony-
matrix tated tissue is available. In adults, the chocutaneous flap from the toe, it is
DP-Ill best treatment is to apply a full. possible to restore the fingertip and
thickness defatted skin graft taken any associated nail involvement.32
from the part. If there are losses in the Brown and associates33 have de-
nail bed o n the remaining digit, a full. scribed an alternative technique to re-
thickness graft of nail matrix can be store the fingertip and nail bed using
Figure 1 The Hirase classification of fin - taken from the amputated part to re- local or regional flaps.
gertip amputation zones based on surgi- store the matrix of the remaining Pocketing has also become a useful
cal t reatment. digit. In children, no defatting is method for fingertip replantation.
done, and the clean amputated part is This technique uses a deep abdominal
accurately replaced with as few su- fascia pocket surrounding a de-
hand. The time the patient takes to
tures as possible in a circular manner epithelialized finger pulp. Kim and
identify the object is also recorded.
so that revascularization may occur. If associates" and Lee and associates 35
Sudomotor function is evaluated by
the amputated part is not brought in believe that pocketing improves sur-
the Ninhydrin sweat test 5 ' 24 or the
or is dirty and therefore unusable, revival of the replanted fingertip be-
wrinkle test. 28 When a peripheral construction is the only option. cause of the vascularity within the
nerve is cut, innervation of the sweat Fingertip injuries have benefited fascia. To be successful, the procedure
glands is lost, and the skin becomes from microsurgical techniques, which must be performed soon after the in-
dry. The return of sudomotor func- add to the variety of treatment jury, before necrosis occms. The
tion closely follows the return of tac- choices. A new understanding of what pocketing procedure is performed af-
tile sensibility. 5' 27 The sudomotor test can be revascularized successfully has ter all other treatments available have
is valued as a confirmation of nerve led to a new classification developed failed. There are also four classic
return. The wrinkle test is performed by Hirase31 that divides the distal modes of reconstructing the fingertip
by placing the hand in warm water phalanx (DP) into several zones based to avoid amputating the distal pha-
(42°C) for 20 to 30 mjnutes. If the on the anastomotic level of the digital lanx. These are fat advancement and
skin is denervated, it will not wrinkle artery and the surgical treatment for split- or full-thickness skin grafting,
because the sympathetic nerve fibers replantation (Figure 1). The anasto- V-Y plasty, cross-finger flaps, and dis-
that supply the sweat glands are ab- motic level is defined as the location tant flaps. These are well described in
sent. at which arterial repair in a replanta- standard texts 36 (Figures 2 and 3).
To more fully evaluate functional tion has been performed. This classi-
activities of the hand, a number of fication allow~ treatment decisions to
tests have been devised that involve be made based on the level of injury. Replantation
marupulating small objects or per- The recommended surgical procedure Since the first report of successful re-
forming activities of daily living. The for zone DP-I amputations is a com- attachment of an amputated thumb
only objective measurement is the posite graft and ice-water cooling. by Komatsu and Tamai37 in 1968, ad-
time it takes to perform the tasks.5 •29•30 Zone II is divided into parts A and B. vances in microsurgical technique
These tests are important because they The recommended surgical procedure and increased experience have made
require a combination of fu nctions for both zones DP-IIA and DP-IIB is replantation routinely possible in rni-
measured by all the previous methods, arterial anastomosis, without using crosurgical centers. In the hand, there
thus measuring the ability to execute Kirschner wires (K-wires) for bone is little or no muscle tissue to sustain
certain tasks by the hand. At present, fixation, if possible. There is no need anoxic damage, and successful replan-
these are the best instruments to eval- to perform treatment for venous re- tation following cold ischernic times
uate hand function as a whole. turn in zone DP-IIA. Zone DP-IIB of more than 30 hours has been re-
should be treated with a partial nail ported . 1 Virtually every person in the
resection and the use of heparin continental United States can there-
Fingertip Injuries ga uze or medical leeches. The digital fore be considered to be within range
Fingertip injuries are very common nerve should be sutured if possible. of a microsurgical center and thus a
among industrial workers and also in The recommended surgical treatment potential candidate for replantation.
childsen. A common scenario is when for zone DP-III is to perform arterial Although there are preoperative

Chapter 13: Partial Hand Amputation: Surgical Management 199
tion (ie, the middle phalanx) usually

do well. They exhibit significantly
better range of motion (approxi-
mately 80° of proximal IP joint mo-
tion) than do replants proximal to the
tlexor superficialis insertion, which
have an average proximal IP joint mo-
tion of approximately 35° . Scott and
associates42 found the total active mo-
tion of replants through the proximal
phalanx to be poor (averaging 120°)
in 84% of their patients. Joint stiff-
ness combined with limited sensibil-
ity may seriously limit the use of a re-
1 planted digit when three normal
I. digits are available for substitution.
Even worse, the impaired function of
the replanted finger may seriously
d jeopardize use of the entire hand.
iS
Causes of limited use may include de-
creased sensibility, pain, cold intoler-
ance, and quadriga. Quadriga is the
1e loss of full excursion in one profun-
:e d us tendon that causes decreased mo-
l- tion in others because of their ana-
ie Figure 2 The Atasoy-Kleinert volar V-Y technique. This is useful in distal f ingertip inju- tomic interco1rnections. For these
f- ries with bone exposed where there is sufficient volar tissue. With volar pad tissue loss,
reasons, many authors no longer rec-
there is usually insufficient skin for this technique to be used. (Adapted with permission
,e ommend proximal replantation of
from Louis OS: Amputations, in Green D (ed): Surgery of the Hand, ed 2. New York, NY,
ic Churchill Livingstone, 1988. Illustration by Elizabeth Roselius, © 1988.) single digits, except in the occasional
ip patient for whom a full complement
a- guidelines for replantation, the ulti- with an intact carpometacarpal artic- of digits is a professional necessity
id mate decision must often be made in ulation.39 Perhaps the most impor- (eg, a musician) or perhaps in chil-
.g, the operating room. The referring tant reason for acceptable function of dren.43
is- physician must take care not to com- the replanted thumb is that no com- The management of one particular
in mit the replantation team to too pletely satisfactory substitute for its type of single-digit amputation, ring
much or too little in preoperative dis- function is available. This not only finger avulsion injuries, has been tl1e
cussions with the patient and family. guarantees that the patient will use s ubject of debate. 43 Although com-
the replanted thumb, but also that the plete amputations by this mechanism
Indications usual activities of daily living will have not been recommended for re-
re- Generally accepted indications for re- maximize restoration of motion. plantation in the past, 44 it has since
nb plantation include amputations of The same considerations also ap- been demonstrated that the level of
1d- multiple digits or those through the ply to replanting multiple fingers. Al- experience of the surgical team and
lUe palm or near the wrist. 38·39 In addi- though the function of each digit may liberal use of vein grafts are of far
1de tion, virtually any amputation in a not be better than that achieved in greater significance than the mecha-
ru- child should be replanted. Although single-digit replantation, these digits nisms of injury in predicting suc-
ere vascular repair is technically more may contribute significantly to overall cess.45
ain difficult in children and success rates hand function when few or no re-
m- lower than in adults, the superior maining normal digits are available Contraindications
nes neurologic recovery in children, par- for substitution.39' 41 In these cases, Relative contraindications to replan-
re- ticularly in yotmg children, makes 1thjs each additional digit, unless it is se- tation include associated life-
the effort worthwh.ile. 40 Most patients re- verely in1paired, can add significantly threatening injury or the presence of
:report excellent levels of satisfaction to the width and strength of the hand. systemic disease, particularly any that
nge with replanted thumbs. Significant Indications for replantation of a would affect the patient's vasculature
IS a stiffness at the interphalangeal ( IP) single digit, except the thumb, are or ability to withstand a prolonged
.on. and metacarpophalangeal (MCP) more controversial. 39 Replantations surgical procedure. Factors pertaining
tive joints does not hamper the thumb distal to the flexor superficialis inser- to the injury itself, including severe

b
p
ous series ranges from rare to nearly I

\ 50% of cases. 41 ' 4 7 The severity of this (]
complication is d ifficult to quantify, I
and tile incidence of bleeding signifi- t
cant enough to require reoperation .a
has not been reported. Postoperative e
heparinization seems to be associated
with higher rates of hemorrhagic \I
complications, and today, most sur-
geons routinely administer heparin
only to tl1ose patients with severe
crush or avulsion injuries in whom
,
the risk of thrombosis is greatest. 47 1
Leeches may also be of benefit if there .a
is difficulty with venous drainage. t
Recovery of sensation following re- 1,
plantation is slightly poorer than tllat a
after digital neurorrhaphy for lacera-
tions of tbe digits. If nerve repair is t
delayed or requires the use of grafts, c
recovery of sensation is not as good as f
with primary repair. Virtually all pa- 1
tients develop protective sensation, J:
and the two middle fingers regain J:
measurable two-point discrimination. I
Approximately one half will exhibit j,
two-point discrimination of 10 mm 1:
or less. 38•41 •42 Gelberman and associ- t

ates29 bave shown a quantitative cor- }
relation between the return of sen- t
sation and restoration of digital
Figure 3 The Kutler lateral V-Y t.echnique for closure of distal fingertip injuries. vascularity. c
(Adapted with permission from Louis OS: Amputations, in Green DP (ed): Surgery of the O ther late complications include L:
Hand, ed 2. New York, NY, Churchill Livingstone, 1988. Illustration by Elizabeth Roselius, bony malunion or nonunion, with an I
© 1988.) c
incidence of less than 5% in most se-
ries, 40 •45 •46 and the almost universal c
presence of cold intolerance.38 •42 Ur- c
crush or avulsion, gross contamina- establish circulation when other tis- baniak and associates43 state that tllis a
tion, the presence of injury at multi- sues at the same level are injured. problem usually resolves spontane-
ple levels, or excessive delay in treat- ously in the year or two following re- a
ment, may also make attempts at Results plantation, altliough it may remain g
replantation inadvisable.41 Once the decision for replantation indefinitely as a minor problem in c
has been made, survival rates in most colder climates. j,
The ultimate question to be an- s
recent series approach 80% to 90% or Secondary operations are per-
swered is whether the replanted part greater at all levels. 38•41 -43.46 T he ma-
will function in a manner that will jor factors influencing survival are the
formed on 15% to almost 50% of pa-
tients, with tenolysis and release of
"s
surpass amputation. Although the age of the patient and experience of joint contractme being the most J:
strictly medical issues involved in the surgeon.43 Early complications re- common procedures.48 Very few pa- c
making such a decision are complex quiring reoperation are related to vas- tients require late secondary reampu- ~
enough, the surgeon must also con- cular occlusion in up to 40% of cas- tation.45 Virtually all patients say they a
sider and discuss with the patient the es.47'48 Slightly less than half of the are satisfied with replantation, with
psychological and economic implica- digits requiring early reoperation are few stating that they would have pre-
tions of tl1e available options. 38 The salvageable.48 Fortunately, infection ferred amputation. 38' 4 1-43
surgeon must remember that tl1e following replantation in the hand is It is difficult to appreciate how pa-
functional results of digit salvage are rare.41 •46 •47 The incidence of postop- tients integrate tile function of the re-
not enhanced by the ability to re- erative hemorrhage reported m van- planted digit or digits witl1 that of the

Ch apter 13: Partial Hand Amputation: Surgical Managem ent 201
remainder of the hand and even more micrnvascular surgical techniques deepens the first web space to im-
difficult to quantify. Data regarding have improved. 49 Only after replanta- prove grip and pinch.
return to work do give some indication is not successful or found to be The web space procedures avail-
tion of fairly normal functional use, not feasible should other reconst:ruc- able include both simple and four-
and the ability to do so is of obvious tive procedures be considered. flap Z-plasties and dorsal rotational
economic, social, and personal signif- Thumb reconstruction requires as- or remote pedicle flaps. These are
icance to the patient. Early return to sessment of the patient's age, sex, oc- most easily performed when the un-
work should be considered a priority cupation, hand dominance, and the derlying soft tissues are minimally
of rehabilitation. 42 ' 43 remaining structure and function of scarred and there is good joint mobil-
the injured hand. The level of ampu- ity. Vvhen there are contractures of
e tation in the thumb determines which the muscles and scarring with loss of
Thumb Amputation
1 procedures should be considered. mobility, a pedicle flap from unin-
7
The thumb is required for both power jured tiss ue must be used. Th is can be
e and precision grip. To achieve this, Amputation of the Distal accomplished by p lacing a cross-arm
the thumb must have adequate Phalanx of the Thumb flap, free flap, or reverse radial artery
length, sensation, and stability as well The functional impairment of ampu- flap into the web space. By deepening
.t as the ability to oppose th e fingers. tation at this level is min imal. Pri- the web space and releasing con-
Loss of the thumb at the level of mary goals are skeletal stability and tracted tissue, the thumb is effectively
.s the MCP joint constitutes a 40% loss
,, of hand function and a 36% loss of
adequate pain-free skin coverage with
good sensation. There are numerous
lengthened .
IS function of the entire upper limb. 16 Disarticulation at the

techniques that will maintain length
,- There is still controversy over exactly
and provide sensation. Metacarpophalangeal Joint
1, how much length must be lost before
For losses of soft tissue dorsally At this level, no normal thumb func-
n impairment is significant. For exam-
with minimal loss of length from the tion remains. Restoration of length,
l. ple, disarticulation through the IP
distal p halanx, healing by secondary stability, sensation, and mobility is re-
it joint of the thumb is rated as a 20%
intention or skin grafting is possible. quired. Lengthening the residuum by
n impairment of the hand. 16 Whatever
If these methods do not provide ade- as little as 2 cm may improve function
I- the amputation level, the patient must
quate coverage, lateral triangular ad- dramatically.
r- have an adeq uate residuum to main-
vancement flaps or pedicle flaps may Procedures that have been used to
l- tain pinch and grip.
be used. gain length and sensibility at this level
al Once length is considered ade-
When the soft-tissue loss is greater are pollicization, including transfer
quate, sensation must be considered,
and there is digital nerve damage, replantation of salvaged injured digits
le including tactile perception and two-
other procedures may be necessary to to the thumb position, or toe-to-hand
.n point stereognosis. Without these, it is
preserve length and maintain good transfers, metacarpal lengthening,
difficult to recognize an object or lo-
sensation. T hese include palmar ad- bone grafting with tubed pedicle
al calize its position in the hand. In ad-
vancement flaps, cross-finger flaps, flaps, and composite radial forearm
r- dition, a functional thumb must have
and neurovascular island flaps. island flaps.49
.is at least protective sensation.49
Sensation must be ach.ieved for
e- Active opposition of the thumb Amputation Through the these techniques to restore usefuJ
e- and index finger is necessary for
Mid-distal Phalanx and function . For this reason, bone graft-
in grasping and pinching, with motion
in occurring at the carpometacarpal Midproximal Phalanx ing with flap coverage is a less satis-
At these levels of amputation, loss of factory alternative. For metacarpal
joint of the thumb. If this joint is de-
length, which affects pinch and grip lengthening, two thirds of the first
:f- stroyed or unstable, it can be fused
with the thumb in a fully opposed po- strength, causes the functional im- metacarpal with good skin coverage
a-
sition in which it serves as a post. T his pairment. The carpometacarpal joint must be present. Pollicization and
of
,st position enables the fingers to brace is usually not involved, tlms preserv- transfer of free tissue offer the best
a- objects against the immobile thum b. ing good rotation and mobility. The chances of restoring thumb function.
u- Motion at the IP or MCP joint is not goals are restoration of length and
Amputation Through the
ey an absolute necessity for normal sensibility.
th thumb function. A free toe transfer satisfies all the
Proximal Third of the First
·e- Resto ration of thumb function by requirements of reconstruction at this Metacarpal
replantation shouJd be considered level. 50•51 If this is unacceptable to the This injmy represents a complete
,a- first after thumb amputation. Replan- patient, other reconstructive proce- functional loss of the thumb and sub-
:e- tation has become a reliable and well- dures can be used, such as "phalangi- total or total loss of the first metacar-
he documented surgical procedure as zation" of the first metacarpal, which pal with resultant loss of mobility

p
closed more easily. If it is difficult to

reduce the space, the fifth metacarpal
base can be allowed to slide spontane-
ously radially if the entire base of the
fourth metacarpal is excised. The fifth
metacarpal can also be transposed to
the base of the remaining fourth
metacarpal after amputation, but this
is rarely necessary.
Fifth ray resections require that the
base of the fifth metacarpal be re-
tained because of the insertion of the
extensor carpi ulnaris (Figure 6). The
hypothenar muscles are used to pro-
A vide padding over the base but are
not reattached to the fourth in-
Figure 4 Technique of index ray amputation. The index metacarpal is transected at the terosseous muscle tendon because
metaphyseal flare. A, Racquet incision. B, Following index ray amputation. (Adapted this, too, can cause an intrinsic plus
with permission from Louis OS: Amputations, in Green DP (ed): Surgery of the Hand, ed
deformity and loss of function.
2. New York, NY, Churchill Livingstone, 1988.)
through the carpometacarpal joint. cosmetic deformities are different for

Finger Amputations
Reconstructive options are essentially each ray. Index ray resection (Figure By definition, finger amputations in-
limited to pollicization and island, or 4) has two potential associated com- volve bone of the fingers. Function
free finger, transfers. If the car- plications to be averted. The first is can be preserved by shortening or
pometacarpal joint is intact with a re- debilitating pai11 resulting from exces- maintaining length, depending on the
sidual portion of metacarpal, a finger sive mobilization of the radial digital anatomic situation. Flap coverage
transfer to the thumb can be per- nerve during surgery. Pain appears in sinlilar to the type used in fingertip
formed with minimal loss of mobility. the first 8 weeks following surgery, inj uries may be used to preserve
tf the entire first metacarpal is absent, and reoperation is not usually suc- length . [f this is unnecessary, then
the finger should be transferred with cessful. The second complication is an bone can be trimmed and the pri-
its MCP joint to preserve some mo- intrinsic plus deformity of the middle mary wound closed.
t ion. finger resulting from transfer of the It is not necessary to remove artic-
Toe-to-thumb transfer is best first dorsal interosseous muscle to act ular cartilage in disarticulations
when other fingers are mutilated. This as the second dorsal interosseous through the IP joints. In fact, there is
is the only technique currently capa- muscle in an attempt to improve the evidence that the inflammatory re-
ble of restoring function when only pinch strengtl1 of the middle finger. sponse to an1putation is less when the
metacarpals remain. This procedure is not necessary, and cartilage is left intact. The condyles,
the resultant deformity will further however, should be trimmed so that
hinder hand function .52 they are not prominent. Both the ten-
Ray Amputations In a middle ray resection, it may be don and the digital nerves should be
Ray amputations are rarely performed difficult to close the space between found and transected so that clean
emergently. They are usually part of tl1e ring a11d index rays (Figure 5). A ends may retrnct proximally. The
the reconstruction of a hand in which soft-tissue closure of ilie gap using flexor and extensor tendons should
an amputation is necessary for the deep intervola r plate ligaments not be sewn to each other because the
trauma, tumor, infection, or failed re- can be performed with minimal rota- excursion of these tendons would be
plantation. If function of a digit is se- tional deformity of tl1e fingers as a re- limited, thus limiting range of motion
verely impaired or if its presence ad- sult (Figure 5, A) . Transferring the in- of the amputated and adjacent fin-
versely affects the function of dex finger metacarpal to the base of gers.
adjacent digits, removal of the entire tl1e middle finger metacarpal is an- The most significant complication
ray should be considered to improve other acceptable method of reducing of amputation at the distal IP joint is
function of the hand as a whole. 36 tl1e gap, giving an excellent functional the lumbrical plus finger. This is
In amputation, considerations for and cosmetic result (Figure 5, B). caused by the flexor digitorum pro-
preventing complications such as Ring ray resections are similar to fundus retracting proximally after
painful neuromas, closing the gap those of the middle ray except that transection. As it retracts, the lumbri-
created between rays, and minimizing the remaining gap can usually be cal muscle is pulled taut. When the

Chapter 13: Partial Hand Amputation: Surgical Man agement 203
dle or ring fingers, a ray resection

should be considered to improve
function. The space left in the center
of the hand cannot be compensated
Index finger
for except by closing the gap with a
metacarpal ray resection or with a prosthesis
(Figure 5, C).
Amputations in children are spe-
cial situations; replantations and re-
vascularizations are always attempted.
Saies and associates 53 studied the rate
of survival of these and found that,
, ~=-v--::::a-..L-H-t-- finger
e like adults, children do better when
base the amputation occurred by sharp
e laceration without crushing. Replan-
tations have a 72% survival rate after
e A B Middle lacerations but have only a 53% sur-
s finger base vival rate after crush or avulsion inju-
ries. When amputation is incomplete
and revascularization is performed,
the rate of survival is 100% after lac-
erations but only 75% after crush or
l· avulsion injuries. In children younger
n than 9 years, the younger the child,
,r the greater the chance of survival for
Le a replanted finger. This age relation-
ship does not hold true for revascu-
.p larization.53
re The reconstructive operations cur-
:n rently used for children who have lost
1- fingers range from great-toe transfers
for thumb restoration, other toe
c- transfers for traumatic digital ampu-
:is tations, pollicization of fingers, and
is modified toe and great-toe transfer
e- techniques. 54 -58 These techniques are
:ie also used in adults for similar recon-
~s, Figure 5 Middle ray resection w ith and w ithout translocation of the index finger. A, structions to improve hand or limb
at Simple middle ray resection. B, Middle ray resection with translocation of the index f in- function. Severe crush injuries result-
n- ger metacarpal. C, Consider ray resection to improve function in middle and/or ring f ining in loss of the entire hand are pos-
ger amputations.
be sible indications for a toe transfer to
an the forearm. The transferred toe can
he patient attempts to flex the MCP and this complication develops in few fin- control a specially designed multiple-
Lid proximal IP joints while making a fist, gers amputated at the distal IP joint. degree-of-freedom electronic pros-
he the involved finger's proximal pha- An amputation through the mid- thetic hand after rehabilitation and
be langeal joint extends paradoxically. dle phalanx distal to the insertion of adaptation training. 59 Brain plasticity
on Tension of the unrestrained flexor the flexor digitorum sublimis tendon facilitates this growing trend of mar-
.n- digitorum profundus tendon is trans- is very functional. If resection is prox- rying reconstructive surgery with
mitted through the lumbrical muscle imal to this, flexion control of the re- prosthetic design.
on to the dorsal hood mechanism to pro- maining middle phalanx is lost, and
: is duce this effect. This can be alleviated disarticulation at the proximal IP
is by releasing the lumbrical muscle joint is recommended. T he proximal
Hand Reconstruction
ro- from its origin on the flexor digi- IP joint should be approached in a When replantation is not feasible af-
ter torum profundus tendon in the palm. fashion similar to the distal IP joint. ter single- or multiple-finger amputa-
,ri- It is tmnecessary to perform this at When amputation through tlle tions, the sUTgeon should focus on re-
the the time of the amputation because proximal phalanx occurs in the mid- constructing the remaining hand so

p
reoperation following amputation

0 ranges from 2% to 25%.60"62
Most complications involve pain 60
= and are therefore at least partially
subjective. The patient's attempt to
come to terms with an amputation
involves a complex and interrelated
series of physical, psychological, emo-
tional, aesthetic, economic, and cul-
tural adaptations. To say that well-
motivated amputees do better may be
trite, but it is also quite true. A review
of patients who underwent amputa-
tions involving the hand revealed few
of these complications, a high level of
acceptance, and an almost universal
return to preamputation activities. 63
A B Pain after amputation may be
caused by inadequate soft-tissue cov-
Figure 6 Ray amputation of the little finger is accomplished by transecting the meta- erage of the residuum, an entrapped
carpal at its base and preserving t he hypothenar muscles to serve as an ulnar pad for neuroma, or pain syndromes such as
the hand. A, Racquet incision. B, Following little finger amputation.
reflex sympathetic dystrophy. Painful
amputations because of adherent or
excessive scarring, poor padding, or
that the patient can wear a prosthesis. When coverage must provide sub- protuberant bone are much more
Preserving the general function of the cutaneous tissue and sensation, po- common in the digits than at the
hand is fundamental to reconstruc- tential donor procedures are a free metacarpal level. These usually result
tion. lateral arm flap or a radial artery fas- from an injudicious attempt to save
When the patient has retained a ciocutaneous flap. The free lateral length at all costs. Although main-
"basic" hand including the thumb arm flap has a very good cushion of taining length is a concern, such re-
and at least one finger, the surgeon fat and fascia as well as a sensory sidua seriously jeopardize function of
must consider the space between the nerve that can be sutured to the recip- the entire hand. Tension-free closure
fingers. Is that space adequate or ex- ient nerve. This is also true for the ra- with appropriate shortening or tissue
cessive? Is there a painful neuroma in dial artery flap, where the superficial transposition should be performed
the midpalmar area that would in- radial nerve can provide innervation. initially.60 Late treatment of such a
hibit function? Is there adequate skin These flaps are capable of withstand- problem is usually best managed by
ing prosthesis use very nicely. Other more proximal amputation, although
coverage? Is there good sensation?
donor sites are available but do not occasionally local flap coverage may
If a contracture exists, that area
provide as good a sensory component be considered for specific indica-
should be released and reconstructed
as these flaps. tions.64 -66
with a Jong-lasting, soft piece of skin,
The incidence of painful neuroma
ideally a distant free flap with sensa-
following amputation in the hand has
tion.
been reported to range from less than
If the patient presents with a Complications 1% to 25% or greater.52•6 1 The num-
thumb and no other digit, recon- Ntunerous complications can occur ber of treatments proposed to prevent
structing an opposing fmger is a pri- after amputation in the band. Al- or manage a painful neuroma is
ority. A toe with its neurovascular though much has been written con- large.67 OccasionaJly, nonsurgical
bw1dle may be transferred to provide cerning solutions to these problems, methods such as desensitization, trans-
an opposing finger. The ideal timing particularly the painful neuroma, few cutaneous nerve stimulation, or neu-
of this procedure is at least 6 months authors have attempted to examine ral blockade may prove to be curative,
after the original injury so that there the true nature and prevalence of but an established painful neuroma
is time for scars to mature and signif- these complications. The incidence of often requires a surgical solu-
icant contractures to develop, allow- complications varies considerably in tion.65•68•69 Tupper and Bootl1 70 re-
ing the surgeon to include more skin the literature, depending somewhat ported a 71 % overall success rate with
with the transferred toe, if needed af- on how diligently the complications simple excision of the neuroma when
ter contracture release. are reported. The reported need for the nerve end was allowed to retract

under cover of more proximal, un- iliis lumbrical plus deformity uncom- References
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,e
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·e-
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,r-
en
2.
e,
K:
,f

Partial Hand Amputation:
Prosthetic Management
Chris Lake, CPO
Introduction
Amputation d istal to the wrist is one from that of the individual with a removed can seriously jeopardize the
of the most common upper limb defi- lower limb deficiency. The signifi- function of the entire hand. 5
ciencies1 and is difficult to treat suc- cance of the physical deficit becomes A myoelectric test of the residual
cessfully with a prosthesis. Reasons apparent when the physiologic com- musculature provides the information
for poor resu lts include functional plexity of lower limb ambulation is needed for consideration of myoelec-
limitations of prosthetic technology, compared with that of upper limb bi- tric prostheses and a means of com -
discomfort at the prosthetic interface, manual manipulation. Each person paring muscle characteristics. Particu-
unsatisfactory appearance, and ab- experiences the amputation through a lar sites to be considered include the
sence of tactile sensation.2 Until the unique perceptual filter, which de- most distal aspects of the wrist flexors
late 1990s, treatment with a prosthesis pends on that person's life history, and extensors, as well as the intrinsic
was limited by the lack of both ac- personality style, stage of life, social musculature found about tl1e thenar
ceptable electronic prostheses and support network, and other factors.3 and hyperthenar eminences. The pros-
precise treatment parameters. As Therefore, the evaluation will be en-
thetist should observe the prospective
Michael3 noted, physicians and pros- hanced by the active participation of sites throughout the range of motion
thetists were chaUenged by the need an occupational therapist and ·a psy-
of the wrist to detect the likelihood of
to identify a prosthesis that would chologist, whose expertise will help in
inadvertent myoelectric signals.
"add a measure of function to dimin- the development of a successful, com-
ish the substantial loss faced by ithe prehensive rehabilitation plan.
partial-hand amputee." The cause of most lower limb am-
By the beginning of the 21st cen- putations is vascular, but approxi-
tury, however, the situation had mately 90% of upper limb amputa-
changed. Advances in upper limb tions involve trauma. 4 Traumatic
prostheses once found only in the reamputations require careful eval ua-
search laboratory had begun to be- tion of scar tissue, range of motion,
come commercially available. The and t issue density (Figure 1).
availability of these new prostheses Sensation in the residual limb
creates a challenge for the treating should be evaluated thoroughly, with
prosthetist. Because many patients loss of protective sensation warrant-
with limb deficiencies distal to the ing the same careful management as
wrist have declined prosthetic inter- does hypersensitivity. Although pain
vention in the past,3 the prosthetist is most common in phalangeal-level
may have limited experience with amputations, pain also may occur in
partial hand amputations. more proximal level amputations.
Pain at these other levels may result
from the surgeon's attempt to save as
Pat ient Evaluation much length as possible. Maintenance Figure 1 Traumatic transmetacarpal-level
Evaluation of the person with an up- of -length is of concern; however, amputation with significant adherent
per Limb deficiency varies greatly keeping tissue that should have been scarring along t he palmar surface.

p
tionaJ and aesthetically pleasing re-

sults often requires fitting the client
w itl1 more tJian one prosthesis. 3 The
fu nctional capacity of the normal hu-
man hand can be compared with that
of a well-equipped toolbox. Therefore,
tl,e person wit!, an upper limb defi-
ciency requires the use of different
prostl,eses to perform the many and
varied activities of daily living, just as
the completion of a large project re-
quires the use of several different
tools. Aesthetic restoration can be crit-
ical to the amputee's acceptance of the
prosthesis, but it is virtually impossi-
ble to maximize both function and ap-
pearance in a single prosiliesis. The
Figure 2 A, Nonarticu lated design immobilizing the w rist. B, Articulated design pre· prostl,etist can achieve a more success-
serves voluntary wrist f lexion and extension. (Courtesy of Otto Bock, USA.) ful result by fitting two different pros-
theses for the same patient.
Finally, limb dominance should be proximal to and encapsulate the wrist
observed because it can dictate a par- (Figure 2). Amputation Levels
ticular physiologic use pattern relative The second goal, bimanual stabil -
to gross and fine motor skills in ity, is to enable the patient to effec-
and Prosthetic
which dominance may indicate a pro- tively manipulate an object or Options
pensity for fine pinch. 6 The rehabili- perform a task using both the con- Partial hand amputation can involve
tation team should consider tJ,e indi· tralateral and affected hands. This various levels of longitudinal and
viduaJ's vocational and other interests goal is directly related to the tJ,ird transverse loss tl,at dictate different
when formulating short- and long- goal, restoration of prehension pat- treatment options. The person witl, a
term goals. terns, wi th regard to a common prob- partial hand deficiency has five fun-
lem in partial band amputees, con- damental prosthetic options: (1 ) no
tralateral overuse syndrome. Results
Goals of Prosthetic of studies of individuals with partial
prosthetic intervention, (2) a passive
prosthesis, (3) a body-powered pros-
Management hand amputations have pointed o ut a thesis, ( 4) an externally powered
Protection of the residual limb is the high incidence of tJ,is syndrome. prosthesis, and (5) multiple task-
fast goal of prosthetic management. Prosthetic studies have indicated a specific prosilieses.
Because many partial hand amputa- 50% likelihood tl1at individuals with
tions are the result of trauma that a unilateral amputation will experi- No Prosthetic Intervention
damages the soft tissues and vascular ence problems in the contralateral Any of a host of factors can lead a pa-
structure of the hand, the residual side.7 Similar results are seen in stroke tient to decline prosthetic manage-
limb can be significantly compro- patients with only one functioning ment. When the individual can main-
mised by pressures exerted by the upper limb.8 ContraJateraJ overuse tain bimanuaJ function with tl,e
prosthetic components in any type of syndrome leads to a decrease in hand residual limb, there may be no need
grasping pattern unless it is protected. function that often is associated with fo r a prosthesis (Figure 3). Also, the
Socket biomechan ics that allow opti- pain and discomfort, and it can ne- residual limb shape may be so unnat-
mal stabilization of the prosthetic cessitate surgical treatment if condi- ural that the patient rejects prosthetic
socket about the residual limb must tions that exacerbate the syndrome fitting because the lin1b cannot be fit
be considered for residual limb pro- are not addressed effectively. The syn- in a manner that is cosmetically ac-
tection. Optimal stabilization can be drome can be alleviated only through ceptable when compared with the op-
ach ieved by several methods, includ- bimanual stability and the restoration posite limb.
ing custom sil icone restoration using of prehension patterns.
a suction fit, non-wrist-encapsulating The last goal of prosthetic manage- Passive Prosthesis
or articulated wrist design that sus- ment is to provide acceptable cosmesis For the individual with a partial hand
pends over the residual anatomy and and durability given the location of deficiency, a passive type of prostl,esis
suction-type interfaces that extend tl1e amputation . Achievement of func- that provides no active movement of

Ch apter 14: Partial Hand Amputation: Prosthetic Management 211
the fingers can offer the restoration of

10
several grasp patterns.9 • A recent
study has shown that individuals with
passive prostheses actively use their
prostheses as frequently as do individ-
uals with functiona l prostheses 11
(Figure 4). Even though passive pros-
theses do not offer active grasp and
release, they can be used to stabilize
objects, to push against items, and to
perform other functional tasks. Th is
Figure 3 Situat ion in which the patient may decline a prosthesis. The bulbous shape of
type of p rosthesis usually incorpo- t he residual limb precludes a cosmetic f inal result.
rates a secure socket that is stabilized
about the residual limb by means of a
total contact suction fit. This type of
socket provides th e fow1dation for
moldable fingers or an opposition
post that can be used to man ipulate
objects. When residual fingers are
present, they can oppose the pros-
ilietic fingers or post and provide ac-
tive grasp and release. Passive pros-
ilieses have been used successfully for
most levels of partial hand loss, as
shown in Figures 5 through 7.
Body-Powered Prostheses
Body- powered prostheses for partial
hand deficiencies can be divided into
two categories: cable-d riven and
wrist- or finger-driven devices. CabEe-
driven partial hand prostheses have
the same inherent advantages and dis-
advantages as do cable-driven pros-
i
theses for amputations at higher lev-
els. Disadvan tages include limited grip
force, discomfort from the required
harness, and reduction of ilie ftmc-
tional envelope secondary to harness
and cable movement. Wrist- or finger-
driven devices can provide active grip Figure 4 Passive prosthesis use. A, Trau-
1-
or pinch force, but actuation may matic t ransmetacarpal-level amputation.
.e B, Appearance of the passive prosthesis.
sometimes inadvertently position the
d C t hrough E, Examples of how the ampu·
fingers in a less functional position.
1e t ee can use the passive prosthesis.
t-
Externally Powered
ic
Prostheses a new electrically powered han d pros- activities. T hese prostheses usually in-
it
:- Until recently, no commercially avail- thesis approximately 3 cm shorter volve some degree of customization
)- able electronic terminal devices suit- than prior options had been used suc- to effectively meet the needs of the in-
able for use with partial hand ampu- cessfully by selected patients with par- dividual. Minimizing the overall
tations were available, although some tial band amputations (Figure 8). length of the prosthesis is always a
efforts to modify wrist d isarticulation concern, but many specialized termi-
id components were reported in the lit- Task-Specific Prostheses nal devices can be modified for use by
;is erature.1 2 However, in 2001, Dietl and Task-specific prostheses are available partial hand amputees, as illustrated
of Hell (unpublished data) reported that for both vocational and avocational in Figure 9.

b
212 Section 11: The Upper Limb
Staging of Care
For the person with a partial hand
amputation, three distinct stages of
care can be defined: preprosthetic,
preparatory prosthesis and interim
therapy, and definitive prosthesis and
therapy. Occupational therapy should
be incorporated throughout aJI
phases of care.
The preprosthetic phase is charac-
terized by therapy designed to prepare
Figure 5 A, Silicone passive prosthesis for a traumatic thumb amputation. 8, Th e ap- the residual limb for fitting. This
pearance of the prosthesis in place. (Courtesy of Life Like Laboratories, Dallas, TX.) phase may involve many techniques
and procedures designed to reduce
edema, preserve and enhance range of
motion, strengthen musculature, and
desensitize the residual limb. The
prosthetist should evaluate the indi-
vidual at this time, discuss all the
prosthetic options, and form ulate the
prosthetic plan in conju nction with a
comprehensive therapy program.
The preparatory prosthesis and in-
terim therapy stage ideally is com-
pleted as soon as possible after the in-
jury, thereby allowing rapid return to
function (Figure 10). It is generally
believed that early return to function
leads to optimal prosthetic function,
and patients who retmn to work
sooner also report increased self-
esteem. 13 During this phase, the pros-
Figure 6 Examples of passive prostheses for metacarpophalangeal (A and B) and meta- thetist and therapist work together to
carpal (C and D) traumatic amputations. (Courtesy of Life Like Laboratories, Dallas, TX.) address the functional limitations of
both the amputation level and pros-
thetic options. If an opposition post
device is indicated, a skilled therapist
can quickly form a temporary device
from low-temperature thermoplas-
tics. Preliminary prosthetic designs
can also be evaluated in the therapy
environment, where input from the
rehabilitation team can be obtained.
This input can provide a valuable as-
sessment tool for the prosthetist be-
fore definitive prosthetic fabrication.
After a thorough assessment,
which can last from several days to
several weeks depending on the com-
plexity of the fitting, the definitive
prosthesis can be provided. At this
stage, the prosthetist and therapist fo-
cus on encouraging the patient to use
Figure 7 A and 8, Opposition post for absent middle, ring, and little fingers. the prosthesis in a wider range of ac-
tivities.

Chapter 14: Partial Hand Am p utation: Prosthetic Managem ent 213
Socket Design
Socket designs for partial hand pros-
theses can permit active pronation,
supination, wrist flexion, and w1·ist
extension. For heavy lifting and simi-
lar tasks, however, it often is necessary
to extend the socket up onto the fore-
arm to stabilize the prosthesis suffi-
ciently, and this longer socket d esign
can interfere with these movements.
One common approach is the use
of dental alginate, rather than plaster
bandages, because the resulting model
is a very accurate representation of
tile three-dimensional contours of rthe
bony residual limb that is typical for
this level of loss. The semiflexible
consistency of alginate makes these
molds well suited for irregularly
shaped residual limbs in which some
distal areas a1·e more bulbous than Figure 8 Transcarpal electronic hand (right) (Otto Bock, Duderstat. Germany) compared
proximal ones (Figure 11). Trimlines w it h a standard Ott o Bock electronic hand (left). (Courtesy of Otto Bock, USA.)
and socket contours are generally dic-
tated by the geometry of the remain-
)
ing portions of the hand and fingers .
Because of the intimate fitting re-
y
quired, as well as the limited surface
11
area distal to the wrist joint, tlle use of
l,
multiple test sockets is almost always
k
necessary. In tlle typical case, the
prosthetist will use local heat to re-
0
form the clear thermoplastic test
,f socket as necessary, often modifying
repeatedly the positive plaster model
,t and molding a new test socket for fur-
Figure 9 Task-specif ic option fo r the partial hand amputee using t he remnant thumb to
st ther fitting trials. Once the socket fits act uat e a quick-disconnect wrist (Texas Assistive Devices, Brazoria, TX).
:e comfortably and range of motion is
,- unrestricted, the desired articulations
lS and components can be added and Components
>y their alignment checked and modified
as necessary.
Passive Prosthesis
1e
d. The passive prosthesis generally is
S- composed of flexible plastic or sili-
Suspension cone material. Polyvinyl chloride is
e-
Suspension is unique to the configu- less expensive, but it stains easily. Sili-
it, ration of the specific residual limb. cone restorations are usually created
to Methods include suction liners, by specialized anaplastic prosthetists,
n- roll-on liners, and anatomically con- who can fashion devices that appear
ve toured designs that suspend over the very lifelike. The prostlletist can
iis residual anatomy. The greater the sometimes modify a standard passive
o- loads to be carried wi th the prosthe- hand, attaching it to the socket and
Figure 10 Fitting a f ully fu nctional in·
.se sis, the more difficult it is to provide blending in the contours so that tl1e
terim prosthesis encourages continued
1C· comfortable suspension witllout in- entire assembly can be covered by the use of t he involved limb for bimanual ac-
terfering with residual wrist motion. same low-cost prefabr icated glove tivities.

Figure 11 Alginate impression technique. A and

B, Significant anatomic landmarks, prospective
electrode placement, and medial-lateral and
anterior-posterior dimensions are delineated at
2-cm intervals from the most distal aspect of the
residua l limb proximally to the cubital fold. C, Al-
ginate is poured into the cylinder as the patient
maintains position of the residual limb approxi-
mately 2 to 3 cm from the bottom of the cylinder.
D, The limb must be supported because any
movement will distort the negative mold. E, The
patient is instructed to relax the res idual limb as
the limb is guided directly out of the cylinder.
Pouring wat er into the top of the cylinder before
removing t he res idual limb will help minimize
suction.
used for wrist disarticulations and by electrodes that are intrinsic o r ex-
higher level amputations. trinsic to the hand. Force Sensing Re-
sistors can also be used at this level.
Body-Powered Prosthesis These input devices consist of a Force
A limited number of commercial Sensing Resistor matrix that the user
components are available to create a activates by means of a pbocomelic
body-powered or externally powered finger or mobile metacarpal.
partial hand prosthesis (Figure 12).
These terminal devices can be inter-
changed between passive task-specific Biomechanics of
Figure 12 Modif ied tools that can be in- prostheses and body-powered cable- Control and
terchanged according to the specific task driven prosthetic limbs.
being performed (Texas Assistive Devices,
Alignment
Brazoria, TX). Externally Powered Biomechanical considerations regard-
Prosthesis ing control and alignment include the
Selected partial hand amputees can use of orthotic principles such as te-
use a special electronic hand operated nodesis action to actuate prehension

Chapter 14: Partial Hand Amputation: Prosthetic Management 215
Figure 13 Wrist -driven partial hand prosthesis (A) al-

lows for varied grip force and enhanced propriocep-
tion. B and C, Extension of the wrist opens the pros-
thesis. D and E, Flexion of t he wrist closes the
prosthesis. (B through E are reproduced with permis-
sion from Nader M (ed): Otto Bock Prosthetic Com-
pendium: Upper Extremity Prostheses. Berlin, Ger-
many, Schiele & Schon, 1990.
d
,e
,d
3t
1e Figure 14 The effect of residual limb alignment on residual limb length. By investigat- Figure 15 Freedom of motion in the ar-
11- ing different positions of the residual limb, the prosthetist can adjust the overall length t iculated design, seen in the preliminary
nt of the prosthesis, allow ing for optimal bilateral symmetry. fitting stage.
<i-
~r.
ny (Figme 13) and harnessing principles
,e similar to those used for higher level
as losses.
er.
,re Alignment often is dictated by the
ze unique contours of the hand rem-
nants, although this can sometimes be
compensated for by adjusting the po-
:x-
sition of the residual limb. Figure 14 il-
le-
lustrates one example in which placing
the residual limb in a certain position
reduced the overall length enough to
rce
significantly improve the symmetr y of
ser
the final prosthesis. If wrist flex.ion
:lie
and extension are retained, this should
be captured in tl1e prostl1esis when-
ever feasible (Figure 15).
Case Studies
Case Study 1
.rd- A 34-year-old woman (Figure 16)
Figure 16 A 34-year-old woman w it h a transmetacarpal-level amputation of the left
the with a transmetacarpal-level amputa- hand. A, Myoelect ric testing before impression. The measurement levels are delineated
te- tion of the left hand secondary to in- circumferentially. B, Diagnostic socket. C, Aligning the hand w hile referencing a mirror
:ion dustrial saw trauma was evaluated ap- so that the patient can provide feedback. D, Finished prosthesis.

proximately L year posttrauma. By

this time, she had undergone six sep-
arate surgeries involving failed re-
plantation, vein and skin grafting, and
management of a bone spur. Residual
limb evaluation revealed significant
scarring and adhesions, and the soft
tissues had a medium to fu-m consis-
tency. Comprehensive evaluation and
treatment included the provision of
both a myoelectric prosthesis for ev-
eryday activities and a passive silicone
restoration for activities such as jet
skiing and other water-related activi-
ties that would damage the myoelec-
tric prosthesis.
The cond ition of the residual limb
indicated the need for an encapsu-
lated design to protect tissue integrity
and increase the weight-bearing sur-
face area. The rehabilitation team will
evaluate the patient's progress in us-
ing this design and the t issue integrity
of the residual limb at regular in ter-
vals before initiating the transition to
a nonencapsulated design that allows
wrist flexion and extension .
Case Study 2
A 30-year-old man with a transverse
amputation involvi ng the left hand,
wrist complex, and fo rearm second-
ary to industrial punch press tra uma
G was evaluated approximately 2 years
posttrauma (Figure 17). By this time,
he had undergone more than 10 sur-
geries to address painful range of mo-
tion. Malrotation of the thumb, di-
minished range of motion, and
m uscle strength test results indicating
less than 1 lb of pinch force limited
the patient's success with his current
passive prosthesis. Following compre-
hensive evaluation, a myoelectric
prosthesis was prescribed for every-
day activities and a task-specific pros-
thesis was prescribed for vocational
activities such as jewelry making.
Summary
Figure 17 A 30-year-old man with a transverse amputation involving t he left hand,
Prosthetic options for partial hand
wrist complex, and forearm. A, Init ial presentation. B. Malrotation of the thumb pre-
venting effective opposition of t he passive f ingers with t he prior prosthesis. C, Prelimi· loss have increased in recent decades
nary prosthesis. D, Preliminary prost hesis. E, Def initive prosthesis. F and G, Occupational to better meet the patient's needs, and
t herapy training. patient acceptance has improved as a
resul t. Research is underway to de-

Chapter 14: Partial Hand Amputation: Prosthetic Management 217
velop smaller, Lighter, and more so- Principles, ed 2. Rosemont, IL, Ameri- unaffected limbs of st roke patients.
phisticated elect ronic terminal de- can Academy of Orthopaedic Sur- Stroke l 999;30:41 4-418.
vices for partial hand amputees. 14 geons, 2002, pp 217-226. (Originally 9. Muilenburg AL, LeBlanc MA: Body-
Improvements in materials and avail- published by Mosby-Yea r Book, 1992.) powered upper-l imb components, in
4. Baumgartner R: Upper extrem ity am - Atki ns DJ, Meier RH Ill (eds): Com-
able components have allowed the
putations, in Surgical Techniques in prehensive Management ofthe Upper-
prosthetist to create specialized
Orthopnedics and Traurnatology. Phila- Limb Amputee. New York, NY,
devices that meet the numerous chal- Springer-Verlag, 1989, pp 28-38.
delphia, PA, Elsevier, 2001, vol 4.
lenges presented by the widely vary-
5. Ouellette EA, McAuli ffe JA, Carneiro 10. Roeschlein RA, Domholdt E: Factors
l ing geometry of partial hand amputa- related to successful upper extremity
f R: Partial-hand amputations: Surgical
tions. prosthetic use. Prosthet Orthot Int
principles, in Bowker TH, M ichael JVv
1989;13:14-18.
(eds:) Atlas of Limb Prosthetics: Surgi-
11 . Fraser CM: An evaluation of the use
Acknowledgment cal, Prosthetic, and Rehabilitation Prin-
made of cosmetic and functional pros-
ciples, ed 2. Rosemont, fl, American
I am grateful to Julie Lake for Literary theses by unilateral upper limb ampu -
Academy of Orthopaedic Surgeons,
review and editing. tees. Prosthet Orthot Int J 998;22:216-
2002, pp 199-216. (O rigi nally pub-
223.
lished by Mosby-Year Book, 1992.)
D 12. Putzi R: Myoelectric partial-hand
Ref erences 6. Swanson AB, de Groot Swanson G, prosthesis. J Prosthet Orthot 1992;4:
Goran-Hagert C: Evaluation of im-
y I. Dietl H, Grope! W: Versorgung nach 103-108.
pairment of hand fu nction, in Hunter
Teilhandamputationen mit myoelek- 13. Malone JM, Fleming LL, Roberson J, et
trischen Komponenten. Orthop JM, Schneider LH, Mackin EJ, Calla-
II al: Immediate, early, and late postsur-
Technik 2001;1:21-23. han AD (eds) : Rehabilitation of the
gical management of upper- limb am-
Hand: Surgery and Therapy, ed 3. St. putation. J Rehabil Res Dev 1984;21:
y 2. Wedderburn A, Caldwell RR, Sander-
Louis, MO, CV Mosby, 1990, pp 109- 33-41.
son ER, et al: A wrist-powered pros-
138.
0 thesis for the partial hand. J Assoc 14. Weir RF, Grahn EC, Duff SJ: A new
Child Prosthet Orthot Clin 1986;21: 7. Jones LE, Davidson JH: Save that arm: externally powered, myoelectrically
,s
42-45. A study of problems in the remaining controlled prosthesis fo r persons with
3. M ichael JW: Prosthetic and o rthotic ar m of u nilateral upper li mb ampu- partial- hand amputations at the
management, in Bowker JH, Michael tees. Prosthet Orthot Int l 999;23:55-58. metacarpals. J Prosthet Orthot
JW (eds): Atlas of Limb Prosthetics: 8. Sato Y, Kaji M, Tsuru T, Oizumi K: 2001;13:26-31.
5e
Surgical, Prosthetic, and Rehabilitation Carpal tunnel syndrome involving
d,
:l-
1a
rs
r-
o-
li-
1d
ng
ed
:nt
:e-
ric
:y-
)S·
1al
.nd
~es
ind
.Sa
de-

Wrist Disarticulation and
Transradial Amputation:
Surgical Management
Patrick Owens, MD
Int roduction
Trauma is the cause of 90% of ampu- require or request revision surgery for proximal levels (Figure 1). Witl1 pres-
tations in the upper limb. lndivid uals shortening of the bone. ervation of the carpus, wrist flexion
age 20 to 40 years are m ost com monl y H igh-voltage electrical burns of the and extension and forearm pronation
affected, with men sustaining fo ur upper limb are a special consideration and supination are maintained. The
times as many am putatio ns as wom- because necrosis of the deep compart- surgical technique is similar to other
en; 1'2 the right and left limbs are af- ment m uscles is often severe, whereas amp utations in the upper limb. The
fected equally. The remaining causes of the superficial muscles may remain vi- palmar-to-dorsal skin flap ratio
amputation in_clude burns, peripheral able. The deep m uscles should be ex- should be 2: J; this allows the carpus
vascular disease, neurologic disorders, plored early and debrided by extensive to be covered with durable palmar
infections, malignant tumors, contrac- fasciotomy. Primary amputations are skin . Wrist motor strength is in-
tures, and congenital deformities. 3 often requ ired, but a longer residual creased by attachment of the wrist
With improvements in limb salvage limb is possible if the superficial mus- flexo rs and extensors to the remaining
techniques, a malignant tumor in a carpal bones. A mobile carpal seg-
cles are viable and are used to enclose
limb no longer automatically necessi- ment covered with sensate skin allows
the rad ius and ulna.5
tates amputation. Microvascular s ur- the patient to perform bimanual ac-
gical procedures have also aided in the tivities without using a p rosthesis.
salvage of limbs after trauma. Despi te Amputation Through Prostheses can be fashioned with ei-
ther a body-powered or a myoelectric
these advances, certain situations still the Carpus terminal device and a socket that ex-
require amputation.
Amputation thro ugh the carpus has tends no farther than the elbow. If the
advru1tages over amputation at more socket is hinged at the wrist, the am-
General Surgical
Considerations
The goal of amputation surgery is a
functional, pain-free resid ual liJnb.
The amputation level is chosen based
on the level of inj ury or extent of the
disease process. In the case of trauma,
all nonviable tissue and foreign mate-
rial must be removed prior to wound
closure. Because this may requi re sev-
eral debridements, pri m ary wound
closure is often contraindicated.
Greater residual limb length can often
Figure 1 Patient with an amputation through t he carpus. A, The residua l limb is cov-
be preserved by covering the wou nd
ered w it h sensate skin, allowing limit ed bimanual f unct ion without a prosthesis. B, The
With split-thickness skin grafts, free prosthesis is articulated at t he radiocarpal joint, allowing easy positioning of t he termi-
flaps, or groin flaps. 4 Patients rarely nal device.

b
A B c
Figure 2 Disarticulation of the left wrist. Active pronation (A) and active supination (B) following wrist disarticulation. C, Lateral view
of the residual limb foll owing wrist disarticulation. Note the smooth distal contours and the impression from a myoelectric limb elec-
trode over the extensor muscle mass. F
/J
ti
v
(1
Figure 3 Wrist disarticulation fol lowing a severe crush injury. A, The hand was painful and tot ally f unctionless, and t he patient re-
quested amputation. B, A ful l-thickness palmar flap is raised. Note the rigidity of the proximal interphalangeal joints. C, Closure of the IF
wound, demonstrating distal coverage with a t hic;k pa!rnar flap. (C is courtesy of J.H. Bowker, MD.) Jl
d
Ii
putee can easily position the terminal thesia include infection at the anes- transected, then allowed to retract v
device by radiocarpal flexion. Despite thesia injection site, coagulopathy, proximally into the soft tissues to t
the functiona l advantage of an articu- lack of patient cooperation, and lack prevent entrapment of neuromas in s
n
lated socket, some amputees prefer a of patient responsiveness. As with the incisional scar. Specifica lly, the
more cosmetically pleasing nonartic- elective amputations through the car- transected end of the superficial ra-
ulated socket. pus, such as for severe brachia! plexus dial nerve should lie beneath the belly a
injuries, vasculopathies, and severe of the brachioradialis muscle. Alter- c
deformities in certain patients, pal- natively, a second, more proximal in- l
Wrist Disarticulation mar and dorsal flaps are created in a cision can be made in the forea rm to c
Amputation through the radiocarpal 2: 1 ratio to provide adequate tissue transect the nerves even farther from t
joint allows the patient to retain virtu- for closure (Figure 3). The flaps the distal end of the residual limb. c
ally full forearm pronation and supi- should include the deep fascia to en- The carpus is carefully separated f
nation. It also provides a long lever sure an adequately padded residual from the radius by d ivision of the ra- f
arm, which facilitates lifting of the ter- limb. 1 In acute traumatic situations, diocarpal capsular and ligamentous c
minal device and its load (Figure 2). where standard flaps may not be pos- structures under traction. If the trian- s
In wrist disarticulation, the patient
is positioned supine on the operating
table. A tourniquet is applied to allow
sible, nonstandard skin flaps should
be used to salvage residual limb
length.
gular fibroca rtilage complex and distal
radioulnar joint are damaged, painful
rotation (pronation/supination) and
,
J
clear visualization of the tissues and The radial, ulnar, and anterior and instability of the radioulnar joint may
minimize blood loss. Prior to apply- posterior interosseous a1·teries, as well result. If reconstruction of the distal ~
ing the tourniquet, the limb may be as the larger veins, must be isolated radioulnar joint complex is not possi- 1
exsangu inated with an elastic bandage and ligated or coagulated. After iden- ble, amputation at the long transradial
or, in the case of tumor or infection, tification of the median, ulnar, poste- level should be considered. The radial
by elevation alone. Regional anesthe- rior interosseous, and superficial and ulnar styloids should be shaped to
sia should be used when possible. radial nerves, they are drawn distally create a smooth, symmetric contour to
Contraindications to regional anes- under moderate tension and facilitate prosthetic fitting; however; to

Chap ter 15: Wrist Disarticulation and Transr adial Amp utation : Surgical Management 221
Figure 4 Use of skin grafting and myoplasty to maintain maximum residua l limb length followi ng traumatic t ransradial amputation.
A, Although no skin remained on the anterior aspect of t he residua l limb, enough muscle t issue was salvageable to cover all but t he
tips of t he radius and the ulna. B, lntraoperati ve photograph of complete split-thickness skin coverage. C, The elbow joint was sal-
vaged by myoplasty and skin grafting. This made it possible to successfully f it the amputee with a prosthesis at the transradial level.
(Courtesy of J.H. Bowker, MD.)
mass, which is especially helpful in

later myoelectric fitting. To obtain the
most functional result, the surgeon
should restabilize the distal muscle
insertion and thereby avoid a mobile
sling of muscle moving over the bone.
The deep layers should be stabil ized
with myodesis or tenodesis directly to
Figure 5 Patient fitted with immediate
bone or periosteum . The more super-
postoperative prosthesis following w rist ficial layers are secured with myo-
disarticulation. The elbow was immobi- plasty to the fascia of the deeper lay-
lized for 1 week post operat ively to pre- Figure 6 Bilateral transradial amputee ers.
ct vent painful stress on the incision. Note fitted with a second set of temporary With very proximal amputations,
[0 the f igure-of-9 harnessing to t he oppo- prostheses. The elbows are free, and the
site shoulder, w hich activates the termi- conj oined harnessing system allows acti-
it may be necessary to detach the bi-
in
nal device. vation of the terminal devices singly or ceps tendon from the radius and re-
1e
together. With t his fitting, the amputee attach it proximally on the ulna. Re-
a- is partially independent in activities of attachment of the biceps tendon too
Jy avoid damage to the triangular fibro- daily living. distally, however, can result in a flex-
:r- cartilage complex, only the tip of the
ion contracture. The radius should
n- ulnar styloid should be removed. The then be removed entirely. Only 4 to
myoelectric prosthesis. The length of
to dorsal and palmar tendons are 5 cm of ulnar length is required for
the prosthesis will be more cosmeti-
,m transected and stabilized under physi-
cally appealing, however, when the prosthesis fitting with retention of el-
ologic tension. The tourniquet is de- bow flexion. To provide a longer fore-
amputation is performed 110 less than
ed flated prior to wound closure to allow arm segment in certain cases, Ilizarov
2 cm proximal to the wrist, thus leav-
:a- for hemostasis. The wound is then bone lengthening techniques have
ing sufficient space for the prosthetic
,us closed in layers, and a bulky compres- been used, sometimes in combination
components.
Lll- sive dressing is applied. with free flap coverage.6 When one
The surgical principles of wrist
:tal disarticulation apply to transradial forearm bone is significantly longer
ful Transradial amputations. Equal dorsal and pal- than the other, and the longer one can
.nd mar flaps are created d istaJ to the in- be covered adequately with soft tissue,
1ay Amputation tended level of bone amputation. The it is preferable to maintain the maxi-
;tal Maximum possible residual limb periosteum is incised sharply, the mum residuaJ limb length rather than
5Sl- length should be preserved in ampu- bones are cut, and the ends are to shorten the longer bone. This can
iial tations through the forearm to main- smoothed carefully. The nerves are be accomplished by fusing the two
:lial tain a stronger lever arm and retain transected as described above and al- bones in a neutral position, creating a
i to maximwn pronation and supination. lowed to retract beneath the muscle one-bone forearm.
r to A very short residual limb may have bellies. Myodesis or myoplasty is per- Coverage is best ach ieved with lo-
r; to difficulty tolerating the weight of a formed to create a stabilized muscle cal skin flaps, taking care to prevent

b
adJ1erence of the skin to underlying Prosthesis Fitting 2. Atroshi I, Rosberg HE: Epidemiology
bone. lf insufficient skin is available, of amputations and severe injuries of
skin grafts, abdominal flaps, or free The most important variable in the the hand. Hand Clin 2001;17:343-350.
flaps can be used for coverage. Skin successful prosthetic rehabilitation of 3. Burkhalter WE, Mayfield GE, Car-
the upper limb is early fitting. Train - mona LS: The upper extremity ampu-
grafts may require additional care ini-
ing with a temporary prosthesis tee: Early and immediate post-surgical
tially but usually do well with matu-
should begin during the immediate prosthetic fitting. J Bone Joint Surg Am
ration (Figure 4). When inadequate 1976;58:46.
soft tissue remains for closure at a de- postoperative period; this can be ac-
4. Rohrich RJ, Erlich man RJ, May JW Jr:
sirable level, free latissimus dorsi flaps complished by adding prosthetic pre-
Sensate palm of hand free flap for
or even innervated free flaps from hension and suspension components
forearm length preservation in non-
amputated parts may be used. to a rigid dressing. The patient can replantable forearm amputation: Long
Nearly one third of transradial am - begin using this immediate postoper- term follow-up. Ann Plast Surg I 991;
putees require revision surgery. This ative prosthesis within 1 to 2 d ays, 26:469-473.
mainly occurs when there has been preserving two-handed grasping pat- 5. d'Amato TA, Kaplan TB, Britt LD:
severe swelling that has receded, leav- terns and decreasing prosthesis rejec- High -voltage electrical injury: A role
ing a bulbous or flabby residual limb, tion rates 3' 7 ' 8 (Figures 5 and 6). Rigid for mandatory exploration of deep
dressings also allow better control of muscle compartments. J Natl Med
or when too much soft tissue was Assoc 1994;86:535-537.
saved at the initial amputation. Every postoperative edema and protect the
6. Kour AK, Seo JS, Pho RW: Combined
effort should be made to maintain wound from external trauma.
free flap, Uizarov lengthening and
even a short transradia] level as long Some surgeons, however, advocate
prosthetic fitting in the reconstruction
as a useful range of motion of the el- the use of compressive elastic dress- of a proximal foreaTm amputation: A
bow can be preserved. ings postoperatively, combined with case report. Ann Acad Med Singapore
Significant flexion or extension early elbow range of motion. Early 1995;24:135.
contractures of the elbow, resulting in prosthetic fitting remains equally im- 7. Tooms RE: Amputations of the upper
loss of function, may develop in some portant in these patients. extremity, in Crenshaw A (ed): Camp-
bell's Operative Orthopaedics, ed 8. St.
patients with transradial amputa-
Louis, MO, Mosby-Year Book, 1992,
tions. Longer residual limbs may ben- References vol 2, pp 711-721.
efit from contracture release. In
l. Baumgartner R: Upper extremity am- 8. Sarmiento A, McCollough NC, Will-
shorter residual limbs, elbow contrac- iams EM, et al: Immediate post surgi-
putations, in DuParc (ed): Surgical
tures can be managed by an elbow ar- Techniques in Orthopaedics and Trau- cal prosthetic fitting in the manage-
throdesis at 90° of flexion rather than matology, Orlando, FL, Harcourt Inter- ment of upper extremity amputees.
by an elbow disarticulation or trans- national, 2003, vol 4. Artif Limbs I 968; 12: 14-16.
humeral amputation.•
American Academy of Orthopaedic Surgwns

Wrist Disarticulation and
Transradial Amputation:
Carl D. Brenner, CPO
Introduction
Several facts relevant to helping upper This trend may be caused by sev- Advantages of Early
limb amputees reach their optimLtm eral factors that are converging. First,
the number of lower limb amputa-
Intervention
n rehabilitation potential are addressed
in this chapter. These facts are: (1) tions is increasing as the population Of the many developments since the
only a very small portion of pros- ages; this may accelerate even more as 1980s regarding management of up-
thetic clinical practice involves the the baby boom generation reaches its per limb amputees, early prosthetic
upper limb amputee; (2) early pros- sixth decade. Second, the number of intervention has had the single largest
thetic intervention is crucial to upper limb amputations may have de- impact. Early intervention, in this
achieving successful outcomes; (3) the creased since the successful imple- context, is defined as the application
patient and health care team should mentation of federal safety regula- of some form of upper limb prosthe-
consider carefully the implications tions under the Occupational Safety sis within the first 30 days after am-
amputation level has for prosthesis and Health Act of 1970, which re- putation.6 The traditional approach,
use; (4) consideration of the five cate- sulted in a much safer workplace. In which delayed prosthetic fitting for
5 to 10 months,7 or until full healing
gories of upper limb prostheses can addition, there have been advance-
had been achieved, yielded a rejection
effectively identify and meet the needs ments in surgical and rehabilitative
rate of at least 50%. s-i O However, the
of upper limb amputees; and (5) elec- techniques related to upper limb sal-
application of a prosthesis within the
tronic limb banking helps reduce vage and reconstruction procedures.
first 30 days of amputation has dra-
costs while enhancing care. At the same time, the number of matically improved long-range out-
board certified prosthetists has in- comes, with some centers reporting
creased more than threefold since
Trends in Upper Limb rates of prosthetic use and acceptance
1971,4 •5 resulting in a further drop in of 90% and higher. 6 •9 This improve-
Prosthetics the number of upper limb fittings ment is believed to be the result of ef-
Overall, most upper limb prosthetic completed by the average prosthetist fective preservation of bi.manual
cases involve wrist disarticulations in general practice. functional patterns resulting from
and transradial amputations. Upper In response to these trends, the early prosthetic training.9 •11
limb prosthetic fittings are declining, American Academy of Orthotists and The use of an immediate or early
especially as a percentage of total. Prosthetists formed the Upper Limb postoperative prosthesis has been
prosthetic fittings. In 1964, Glatt1y1 Prosthetics Society in 1991 to provide shown to be effective in achieving the
reported that of all prostheses pre- a forum for education and communi- goals of early intervention, which in-
scribed, 1 in 7 were fitted for upper cation among the practitioners of this clude decreased edema, decreased
limb patients; 10 year~ later, Kay and specialty. The realization that upper postoperative pain and phantom
Newman 2 reported that upper limb limb prosthetic fitting and care re- pain, increased prosthetic use,
fittings represented only 1 in 12 pros- quire special expertise on the part of improved proprioceptive/prosthetic
theses. In 2001, the American Ortbotic both the prosthetist and the occupa- transfer, and improved psychological
and Prosthetic Association reported tional therapist will result in im- adaptation to the amputation. 6 •9• 11 Al-
that only 1 in 15 fittings was for an up- proved care for all upper limb ampu- though this procedure has been used
per limb prosthesis.3 tees. widely in lower limb applications since

224 Section II: T h e Upp er Limb
11
TABLE 1 Ideal Prost hesis Fitting Timetable for Wrist Disarticulations and
Transradia l Level Amputations B
aJ
Type of Prosthesis Postoperative Application 0
Immediate or early postoperative prosthesis 24 hours to 14 days n
Preparatory/training body-powered prosthesis 2 to 4 weeks tf
Definitive body-powered prosthesis 6 to 12 weeks ti
Preparatory/training electronic prosthesis 6 to 12 weeks cl
Def initive electronic prosthesis 4 to 6 months
the late 1960s, it has remained un- the fitting process. A shorter residual c;
Figure 1 A second layer of stockinette is
derutilized in upper limb applications limb is especially advantageous if the applied over t he dressing of a w rist disar- tc
despite the fact that it does not jeop- amputee will alternate between an ticulation to facilit ate easy removal and S<
ardize wound healing in the upper electronic prosthesis and a body- application of the postoperative prosthe- 0
limb, as is sometimes the case in powered prosthesis. sis.
tl
weight-bearing lower limb situa- For the amputee to receive all the sc
tions.9'11 potential benefits of wrist disarticula- p
Immediate and Early
tion, the residual limb must retai11 a p
Postoperative Prostheses
large percentage of normal pronation ti
Wrist Disarticulation The first early intervention decision
and supination after surgery and SJ
Versus Transradial must be covered with durable skin to be considered is whether to provide ti
Amputation: and soft tissues that will tolerate susan immediate or early postoperative sl
prosthesis. An immediate postopera-
Prosthetic pension forces applied just proximal
tive prosthesis is appHed in the oper-
sl
to the styloids. Although specialized p
Implications terminal devices are available for ating room at the time of final surgi- (
The long-standing principle in ampu- wrist disarticulation applications, the cal closure, whereas an early tl
tation surgery is to "save all length." choice of components is much more postoperative prosthesis is applied a
The advantages of clisarticulation sur- limited when compared with those any time between surgery and suture l<
gery through the wrist over a higher available for transradial amputations. removal. There appears to be no sig-
level amputation have been under- The patient should be aware of the nificant difference in long-range out- F
stood for decades. However, two ma- trade-offs in appearance and options comes between immediate and early E
jor issues are limb length and residual that a wrist disarticulation requires postoperative application in the up-
1
pronation and supination. With a and should feel that the benefits of per limb; however, immediate appli-
ti
wrist clisarticulation, the use of a added leverage, voluntary pronation cation can provide additional psycho-
logical benefits to the patient and the iP
prosthesis will frequently result in a and supination, and distal suspension
patient's family.6 ·9
b
length discrepancy that is cosmetically outweigh the limitations. t
unacceptable to the patient. 10 Th is is Essentially, the same technique is
l,
particularly true when a qu ick- used for both procedures. First, two
disconnect wrist is employed to pro- Types of Prostheses separate layers of stockinette a1·e ap-
t
a
vide easy interchangeability between a Used in Upper Limb plied d irectly over the dressing (Fig-
f
hook terminal device and an elec- ure 1), followed by distal padding that
Reha bi Iitation consists of lamb's wool, sterile fluffs,
t
tronic hand. In addition, if adequate
Five distinctly different types of pros- c
residual pronation and supination are or a reticulated methane foam pad.
r
absent, disarticulation surgery is usu- theses make up the armamentarium The padding is then covered with a
necessary to provide optimum and thin cast/socket fabricated of plaster c
ally contraindicated because the am-
comprehensive management for the a
putee will have active wrist rotation or fiberglass casting tape (Figure 2).
upper limb amputee. T hey are (1) im- t
only if there is sufficient room for an This socket extends to the level of the
electronically controlled wrist rota- mediate/early postoperative, (2) pre- epicondyles but leaves the elbow free.
tion module. If skin grafting would be paratory/training body-powered, (3) A thermoplastic frame with a light-
necessary to preserve the viability of a definitive body-powered, ( 4) pre- weight terminal device is then taped
disarticulation surgical level, a higher paratory/training electronic, and (5) in place with a good-quality linen ad-
level amputation just proximal to the definitive electronic prostheses. The hesive tape (Figure 3), followed by a
graft site may prove to be a more ap- fitting timetable for the use of these similar application of tape to affix the
prnpriate decision to avoid delays in prostheses is shown in Table 1. flexible elbow hinges that are con-

Ch apter 16: Wrist Disarticulation and Transradial Ampu tation: Prosthetic Management 225
nected to the triceps pad. A standard

Bowden cable assem bly is applied,
and either a shoulder saddle harness
or, more typically, a figure-of-8 har-
ness is employed for suspension and
termi nal device control. When all of
the components have been taped to
the cast/socket, a final covering of a
self-adhering elastic bandage is ap-
plied to reinforce the fixation of ·the
componen ts (Figu re 4). No synthe tic
casting tape or plaster should be used Figure 2 Fiberglass casting tape is rol led Figure 3 A thermoplastic frame is posi-
to attach the components to the inner over the distal pad of reticulated foam. t ioned to hold a lightweight terminal de-
The cast is terminated just distal to the vice, in this case an aluminum model SXA
socket, thereby ensuring easy removal hook and friction wrist, in place.
epicondyles to allow free elbow flexion.
of the components when chang ing
the cast/socket. The two stockinette
socks applied at the beginning of the
procedure allow easy removal and ap-
plication of the postoperative pros-
thesis, which faci litates wound in-
11 spection and management. 9 However,
e the patient and the nursing staff
e should be advised that removal
1-
should be done for only very shor t
periods of time to minimize edema.
I- Figure 5 This preparatory/tr<1ining body-
Occupational therapy with this pros-
1y Figure 4 A final covering of a self- powered short transradial prosthesis is
thesis generally can be started as soon
d adhering elastic bandage is used to rein- shown with a thermoplastic socket,
as the patient is alert and able to fol- single-axis elbow joint, Bowden cable as-
:e force the fixation of the components.
low directions.9 • 11 This early postoperative w rist disarticula- sembly, and an interchangeable quick-
J-
disconnect locking w rist with a stainless
't- tion prosthesis is shown with a figure-
Preparatory/Training of-8 harness, triceps cuff, and flexible el- steel model 7 work hook.
ly Body-Powered Prostheses bow hinges.
J-
The second type of prosthesis used in and allows the amputee to practice
.i-
the management of upper limb am- The goals of the preparatory/ using a body-powered prosthesis for
)-
putees is the preparatory/training training prosthesis are preparation of the normal activities of daily living.
1e
body-powered prosthesis. T his pros- the limb for prosthesis use, evalua-
thesis is applied when the wound has tion, and training. In terms of prepa- Definitive Body-Powered
is
healed and the immediate postopera- ration , the prosthesis provides contin- Prostheses
110
tive edema has resolved. The prep- ued edema control, a reduction in Once the patient has worn a postop-
p-
aratory/training prosthesis differs patient pain and anxiety, and condi- erative prosthesis until the wound is
g-
tat from the postoperative prosthesis in tioning of the tissues to accept the healed, fo llowed by a preparatory
ts, that the preparatory socket is made forces exerted by a prosth etic socket. body-powered prosthesis until the
1d. over a plaster model of the patient's As an evaluation tool, the prosthesis limb volume has stabilized, the for-
I a residual limb, the prosthesis is fabri- helps the clinic team and the patien t mulation of definitive prosthetic pre-
ter cated from more durable materials, determine which components provide scrip tion specifications is relatively
2). and its design allows for the easy in- the greatest benefit, aids the rehabili- straightforward. If the two previous
:he terchangeability of various compo- tation team in assessing the patient's p rostheses accomplished the goals of
ee. nents during the evaluation process level of motivation and compliance, providing a comprehensive evaluation
ht- (Figure 5). To achieve a successful and allows the patient to become fa- of the socket design and the harness-
>ed outcome, a preparatory/training pros- miliar with the functional value and ing system and of determining w hich
:1d- thesis sho uld be designed and fitted limitations of a body-powered pros- wrist and elbow components proved
ya with the same care as a definitive sys- thesis. W ith regard to trai ni ng, the most functional, then most elements
the tem, including the use of test sockets preparatory prosthesis helps the pa- of an appropriate prescription be-
)n- when necessary. tient preserve two-handed function come evident based on the patient's
b
Elbow Joints cross point or a ring to provide ad-

The flexible elbow hinge is the most justable posterior fixation for all the
common type of elbow joint used straps. The shoulder saddle harness is
with a wrist disarticulation or trans- beneficial for amputees who do an
radial amputation. It can be made of unusual amount of heavy lifting (Fig-
either triple-thickness Dacron web- ure 6). It also provides relief from
bing or flexible metal cable. 'When some of the pressure on the axiUa ex-
socket rotation arow1d the residual erted by a figure-of-9 or figure-of-8
limb becomes a problem secondary to harness. However, the shoulder saddle
a very short bone length, a single-axis harness is frequently rejected by pa-
elbow joint is the most effective way tients who prefer to wear an open
to provide stability. In those rare in- V-necked shirt or blouse that would
stances in which the patient has very expose the chest strap.
limited elbow flexion and it is crucial
to reach the face witl1 the prosthesis, Advantages and
as in the case of the bilateral amputee, Disadvantages
step-up hinges may prove beneficial. Among the advantages of the body-
powered prosiliesis are the freedom to
Wrist Components operate in an unencumbered manner
The four most commonly used wrist within most physical environments
units are tlle standard friction wrist, and the ability to achieve a high level
the quick-disconnect/locking wrist, of accuracy and speed during func-
Figure 6 A definitive body-powered
the flexion wrist, and the multidirectional performance. 10• 12, 13 The pri-
transradial prosthesis with triceps cuff,
flexible elbow hinges, laminated socket, tional ball-and-socket wrist. For adult mary disadvantages of the body-
and shoulder saddle harness with unilateral amputees who use more powered prosthesis are the discomfort
Bowden cable control. than one terminal device or routinely caused by the shoulder harness and
perform activities that require the the appearance of the hook terminal
actual experience. However, several elimination of any unwanted wrist device, which can generate negative
rotation during functional perfor- attention. 10•13
additional factors should be consid-
mance, the quick-disconnect/locking
ered when developing definitive spec-
wrist has proved to be most useful.
ifications, including the socket design,
When normal functional perfor- Preparatory/Training
the elbow joint, the wrist component,
mance of the contralateral upper ex- Electronic Prostheses
and the harness design.
tremity has been compromised, or for
Since the 1980s, electronic and micro-
Socket Designs bilateral amputees, a flexion wrist
processor technology has made signif-
may be appropriate to add an addi-
Sockets designed for use with body- icant contributions to the field of
tional measure of function. A stan-
powered prostheses are either prosthetics, leading to increasing
dard friction wrist is the most popu-
harness-suspended or self-suspended. complexity and a much broader array
lar and economical component that
As a general rule, the longer the resid- provides passive wrist rotation. A of options for the upper limb ampu-
ual limb, the lower the proximal trim multidirectional ball-and-socket wrist tee. Although this has led to improved
line of the socket can be. 'When tl1e unit provides not only wrist flexion electronic prostheses, it has also com-
patient retains a significant amount but also wrist extension as well as ra- plicated the decision-making process
of natural pronation and supination dial and ulnar deviation. for tlle prosthetist. Fortunately, the
after surgery, the proximal trim line use of a temporary electronic pros-
of the socket should be cut low Harness Designs thesis allows the clinician and the pa-
enough to preserve at least 50% of the The three basic harness designs are tient tl1e opportunity to evaluate and
active pronation and supination. Al- the figure-of-9, the figure-of-8, and experience many different design and
though several self-suspended sockets the shoulder saddle harness with a component options before coming to
are now available for wrist disarticu- chest strap. The figure-of-9 harness is a final conclusio~.1 4 - 16 Therefore, the
lations and long transradial level amused primarily with a self-suspended preparatory/training electron ic pros-
putations, most designs require some socket that requires a harness only to iliesis should be considered a separate
form of suspension/control harness provide terminal device operation. and distinct procedure in the total
and so significantly restrict range of The most popular harness, the figure- evaluation process of the upper limb
motion. of-8, can be fitted with either a sewn amputee's needs.

Chapter 16: Wrist Disarticulation and Transradial Amputation: Prosthetic Management 227
Fitting and Controls more body-powered controls, in

The fitting of a preparatory electronic which case it is called a hybrid sys-
tern.1 4 Although hybrid systems are
prosthesis should be conducted with
the same care as the fitting of any de- used primarily in amputation levels
above the elbow, they may also be in-
finitive prosthesis. However, the less
dicated for a patient with marginal el-
expensive fabrication process and
bow function. Such situations may re-
components provide a very cost-
quire step-up body-powered elbow
effective way of analyzing the patient's
e hinges in conjunction with either a
needs.
switch controlled or myoelectrically
Careful fitting of the temporary
controlled terminal device and/or
n prosthesis ensures that the experience
wrist rotator.
d of the patient while wearing the
prosthesis will be very dose to the ex-
perience of wearing a more costly Goals of the
definitive electronic limb. The same Preparatoryffraining
techniques are used for taking the Electronic Prosthesis
r- negative plaster mold of the residual As with the preparatory/training
:o limb and subsequent modification as body-powered prosthesis, ilie goals of
er with a definitive fitting. A transparent the preparatory/training electronic
ts test socket is then made over the mod- prosthesis a1·e preparation of the re- Figure 7 A preparatory/training elec-
el ified plaster model, and this is used to sidual limb for prostl1esis use, evalua- tronic transradial prosthesis with North·
c- evaluate the suspension and stability western supracondylar socket w ith ole-
tion, and training. By way of prepara-
cranon cut -out and removable f itting
'l- of the socket design and establish election, the prosthesis helps establish frame.
y- trode sites. The test socket is then used ideal definitive myoelectric signal
1rt to create the final positive master sites, provides the opportunity to im-
1d model over which the preparatory prove marginal myoelectric signals, determine the specifications for the
1al electronic socket will be fabricated. and helps condition the tissues con- definitive prosthesis. Because no con-
ve Once the socket has been fabricated, it tained within a self-suspended socket. sensus exists regarding the respective
is attached to a removable fitting In terms of evaluation, ilie prosthesis advantages of body-powered and elec-
frame that connects to the electronic has four specific objectives: (1) vali- tronic prostheses, providing the am-
components and protects the wiring dation of the socket design and se- putee an opportunity to personally ex-
and electronic circu its. Finally, a stan- lected electronic components, (2) as- perience the actual benefits and
dard protective outer glove is applied sessment of the patient's motivation limitations of each of these systems al-
over the prosthesis to cover the inner and commitment to derive maximum lows the final choice to be made with
:o-
shell of the electronic hand (Figure 7) . benefit from an electronic prosthesis, some assurance that no major over-
1if-
lt is very important tl1at the patient (3) provision of the patient with the sights have occmred. In today's healtl,
of
receive preprosthetic myoelectric sig- opportunity to determine the actual care environment, resources and
lng funding are limited; therefore, effec-
nal training prior to the start of pros- functional value of the electronic
ray tive methods for evaluating expensive
ilietic fabrication and fitting. Follow- prosthesis when compared with other
)U-
ing the fitting, the patient should options, and ( 4) the development of technology should be used whenever
red clinical evidence to substantiate a possible. Because work-related inju-
continue with occupational therapy
m- cost-benefit analysis of various alter- ries are one of the prime sources of
that stresses the specific activities that
:ess natives. The training objectives of a upper limb loss, the ability of ampu-
relate to the patient's daily rou tine,
the temporary electronic prosthesis in- tees to return to work has proved to be
both on and off the job.
·os- Although most electronic prosthe- clude refinement of the patient's over- a useful measure of a successful out-
pa- ses primarily use myoelectric signals all prosthetic control and the oppor- come. Most amputees treated with
rnd to command the prosthesis, three t unity to practice activities of daily the comprehensive methods presented
and other electronic control modes can be living with an appropriate electronic here have returned to work.6 •9 • 13
po used in a preparatory or a definitive limb.
the electronic prosthesis. These are elec- Socket Designs
ros- tronic servo controls, electronic
Definitive Electronic One important decision is the choice
rate switch controls, and electronic touch Prostheses of socket design. Ideally, the patient
otal controls. 14• 17 • 1s A prosthesis can h ave After proceeding through the four will have had the opportunity to try
imb a combination of one or more elec- types of prostheses, the amputee and more than one type of socket suspen-
tronic controls in addition to one or the clinic team are now positioned to sion at the time ilie test sockets were

p
from using residual voluntary prona- tr

tion and supination. el
Suspension designs that involve el
suprastyloid purchase use three types ti·
of suspension. These designs include ie
silicone bladder suspension, window/ cc
door suspension with elasticized clo- ti,
sure, and soft removable inserts that cl
grip the styloids. cc
The last category of socket designs P·
are those that use internal roll-on tr
locking liners. These designs use ei- p1
ther a shuttle-lock system for short Iii
and midlength transradial level am- bt
putations (Figmes 10 and 11 ) or a e1
lanyard locking system for long trans- dj
radial amputations and wrist dis- s~
articulations.22 -24 b,
The latter two suspension methods el
Figure 8 A definitive electronic wrist dis-
Figure 9 A definitive electronic transra-
can be combined with abbreviated tt
articulation prosthesis with a rnyoelectric trim lines that terminate well distal to b;
dial prosthesis with external silicone sus-
greifer, quick-disconnect w rist, and float-
pension sleeve and rnyoelectric hand. the epicondyles. This permits the am- Sl
ing brim suspension.
putee to use residual pronation and cl
supination to position the tenninal
device precisely. te
The specific suspension method tt
selected for the definitive prosthesis is ti
based on how effective and comfort- el
able prior suspension methods have el
proved to be for the patient's custom- tc
ary activities. Ease of application and IT
removal are also important factors for p:

Figure 10 An internal roll-on locking Figure 11 A preparatory/training rnyo- o:
electric transradial prosthesis with inter-
consideration.
liner with distal shuttle-lock pin and inte- le
grated snap-on electrodes. nal roll-on suction liner, shuttle-lock sys-
tem, and snap-on electrode wire harness. Cost and Maintenance rr
When considering the viability of se- b
being evaluated. This is particularly lecting electronic prostheses, the is· p
20
ID1"dl engthtransra d"iaJ amputations,
.
sues of cost and maintenance should a
important with wrist disarticulations
the modified supracondylar brim be addressed. Although cost has long ci
or long transradial amputations.
with an olecranon cut-out for long been a major obstacle in providing le
Socket designs fall into four basic cat-
transradial amputations, 2 1 and the advanced technology to amputees, in St
egories: ( 1) supracondylar brims that
floating brim suspension for long the past decade, most amputees have p
capture the humeral epicondyles and
transradial amputations and wrist been found to have sufficient health p
the posterior olecranon, (2) external disarticulations (Figure 8). The exter- b.
care insurance to cover the cost of
suspension sleeves that use either at- nal sleeve suspension techniques in- n
these procedures. 16•25 In addition,
mospheric pressure or skin traction clude latex rubber or sili~one sleeves, rr
many upper limb losses occur in job·
to maintain suspension, (3) stprasty- which rely on atmospheric pressure p
related situations and are covered by
loid suspensions for wrist disarticula- suspension (Figure 9); neoprene p
workers' compensation programs. As
tion amputees with prominent sty- sleeves, which rely on a combination a result, funding no longer presents 0
loids, and (4) internal roll-on locking of atmospheric pressure and skin insurmountable obstacles .for most ti
liners. 19 traction; and elastic sleeves, which patients. fc
Four basic types of supracondylar provide skin traction suspension, re- The recent formation of electro11ic
designs are reported in the liter-
A
lying only on the grip of a breathable limb banks and leasing programs has
ature: the Muenster socket for short elastic sleeve on the skin. Because made a favorable impact o n the cost
c
transradial amputations,1° the North- these designs extend beyond the el- and complexities of providing sophis- F
a,
western supracondylar socket for bow joint, they prevent the amputee ticated electronic limbs. 16 •25 Elec-

Chapter 16: Wrist Disarticulation and Transradial Amputation: Prosthetic Management 229
tronic limb banks collect a variety of is the freedom from a control/ 2. Kay HW, Newman JD: Amputee sur-
electronic components, including suspension harness through the use of vey, 1973-74: Preliminary findings and
electronic hands, electrodes and elec- a self-suspended socket that provides comparisons. Orthot Prosthet 1974;28:
tronic switching mechanisms, batter- a maxinmm degree of comfort. 10 27-32.
ies, and battery chargers. All of these Other amputees report that the ability 3. 2000 Orthotics and Prosthetics Business
components can be leased to the pa- to function with a prosthesis that has and Salary Survey Report. Amer ican
Orthotic & Prosthetic Association.
tient on a trial basis for a modest a close resemblance to a normal hu-
charge. For a fraction of the purchase man hand is most important. 14 •27 4. 1971 Registry. American Board for Cer-
t
t ification in Orthotics and Prosthetics.
cost of new electronic hardware, the Reported disadvantages include
patient can obtain the necessary elec- that although the electronic terminal 5. 2001 Registry and Reference Guide.
s
American Board for Certification in
11 tronics in a preparatory/training device generally provides a much
Orthotics and Prosthetics.
prosthesis. There are three types of stronger grip force, it may be some-
6. Malone JM, Fleming LL, Roberson J, et
limb banks, with the most common what slower in operation than a body-
al: Immediate, early, and late postsur-
being a private limb bank that is gen- powered hook. 13•27 Second, the lack of
gical management of upper-limb am-
a erally organized and funded by an in- freedom to use the electronic prosthe-
putation./ RehabilResDev 1984;21:
dividual prosthetic .laboratory. The sis in hostile environments where dii1, 33-41.
;- second type is a commercial limb water, dust, grease, and solvents are in 7. Davies E). Friz BR, Clippinger FW:
bank sponsored by a manufacturer of freq uent contact with the prosthesis Amputees and their prostheses. Artif
ls electronic limb components, and the has proved to be a major draw- Limbs 1970;14:19-48.
d third type is an institutional limb back.10· 14·16 However, the p roblem of a 8. LeBlanc MA: Patient population and
:o bank that is generally organized and hostile environment has been partially other estimates of prosthetics and
l- supported by either a hospital or a remedied by the availability of various orthotics in the U.S.A. Orthot Prosthet
id charitable organization. 16•25 electronic hook terminal devices. As a 1973;27:38-44.
al A seconda1y concern is the main- result, many amputees have found that 9. Malone JH, Childers SJ, Underwood J,
tenance and corresponding downtime the best solution is to have both a Leal JH: Immediate postsmgical man-
,d that may be associated with the con- body-powered and an electronic pros- agement of upper-extremity amputa-
is tinuous operation of a sophisticated thesis available to use at their discretion: Conventional, electric and myo-
14 28 electric prosthesis. Orthot Prosthet
t- electronic system. For the most part, tion, depending on the situation. ·
electronic prostheses have been found 1981;35:l-9.
ve
to require maintenance at approxi- 10. Northmore-Ball MD, Heger H, Hunter
n-
1d mately as often as do body-powered
Summary GA: The below-elbow myoelectric
prosthesis: A comparison of the Otto
'or prostheses. However, because repairs Each of the five types of prostheses
Bock myoelectric prosthesis with the
of electronic prostheses tend to take used in upper limb rehabilitation has a
hook and functional hand. J Bone Joint
longer, the downtime required for very specific role in the comprehensive Surg Br 1980;62:363-367.
maintenance can be a major stum- care of upper limb amputees. Each
11. Burkhalter WE, Mayfield G, Carmona
;e- bling block unless the services are system can provide information to LS: The upper-extremity amputee:
is- provided by a specialty center that has guide decisions that lead to the best Early and immediate post-surgical
tld a service delivery system that effi- outcome for each individual amputee. prosthetic fitting. J Bone Joint Surg Am
ng ciently deals with the unique prob- Although circumstances may not per- l 976;58:46-51.
.ng lems of repairing electronic prosthe- mit or necessita te the use of all five 12. Billock JN: The Northwestern Univer-
in ses.16'26 Electronic limb banks have systems for every patient, the use of sity supracondylar suspension tech-
1ve proved to be the best solution to the two or three of these techniques is al- nique for below-elbow amputations.
Ith problem of downtime. Such li.mb most always possible and indicated. Orthot Prosther 1972;26:16-23.
of banks provide a replacement compo- Following this model assures the pa- 13. Kritter AE: Myoelectric prostheses.
on, nent that can be installed when im- tients, the patients' fam ilies, clinicians, J Bone Joint Surg Am l 985;67:654-657.
)b- mediate repair of the prosthesis is not caregivers, and th ird-party payers that 14. Millstein SG, Heger H, Hunter GA:
by possible. 16•25 The solution that ap- the highest quality and most cost- Prosthetic use in adult upper Limb
As pears to be forthcoming is the devel- effective methods have been used to amputees: A comparison of the body
opment of regional specialty centers help upper limb amputees reach t heir powered and electrically powered
:nts
that can provide immediate service maximum rehabilitation potential. prostheses. Prosthet Orthot Int 1986;
1ost
10:27-34.
for electronic prostheses.26
15. Billock JN: Upper limb prosthetic
,nic
has Advantages and References management: Hyb rid des ign ap-
Disadvantages I. Glattly HVJ: A statistical st udy of proaches. Clin Prosthet Orthot 1985;
:ost 9:23-25.
For most adult amputees, t he biggest 12,000 new amputees. South Med J
his-
I 964;57: 1373- I 378.
lec- advantage of an electronic prosthesis

b
16. Brenner CD: Electronic limbs for in- 21. Sauter WF: Three-quarter-type Muen- Prosthet Orthot 1985;9:l 7-J 8.
fants and pre-school children. ster socket. J Assoc Child Prosthet 26. Brenner CD: Demographic and logis-
J Prosthet Orthot 1992;4:24-30. Orthot Clin 1985;20:34. tical considerations for pediatric elec-
l 7. Su pan TJ: Transparent preparator y 22. Daly W: Clinical application of roll-on tronic limb applications. Journal of
prostheses for upper limb amputation. sleeves for myoelectrically con trolled Proceedings, AAOP 19th Annual Meet-
Clin Prosthet Orthot 1987;1 l :45-48. transradial and transhumeral prosthe- ing and Scientific Symposium, 1993,
ses. J Prosthet Orthot 2000;12:88-9 1. p l l.
18. Michael JW: Upper limb powered
components and controls: Current 23. Heim M, Wershavski M, Zwas ST, 27. Stein RB, Walley M: Functional com-
concepts. Clin Prosthet Orthot 1986; Siev-Ner I, Nadvorna H, Azaria M: parison of upper extremity amputees
10:66-77. Silicone suspension of external pros- using myoelectric and conventional
theses: A new era in artificial limb us-
19. Nichol WR: Electron ic touch controls prostheses. Arch Phys Med Rehabil
age. J Bone Joint Su,g Br 1997;79:638-
for prostheses. J Assoc Child Prosthet l 983;64:243-248.
640.
Orthot Clin 1986;21 :33. 28. de Bear P: Functional use of myoelec-
24. Salam Y: The use of silicone suspen-
20. Gaber TA, Gardner CM, Kirker SG: sion sleeves with myoelectric fittings. tric and cable-driven prostheses.
Silicone ro ll-on suspension for upper J Prosthet Orthot l 994;6:119-120. J Assoc Child Prosthet Orthot Clin
limb prostheses: Users' views. Prosthet l 988;23:60-61.
25. Epps CH Jr: Editorial: Externally pow-
Orthot Int 200 I ;25: 113- J18. ered prostheses for children-1984. Clin
11
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The Krukenberg Procedure
Pradip D. Poonekar, MD
Introduction
The human hand represents a major ians. This operation reshapes the In patients with congenital upper
milestone in human evolution be- forearm of the traJ1Sradial amputee limb deficiency, the operation is ad-
cause of its highly specialized struc- into muscle-powered sensate radial vocated beginning at 2 years of age
ture and function. Even the most so- and ulnar rays that effectively fimc- with consideration for the associated
phisticated prosthetic terminal devi.ce tion as forceps,4 " 6 chopsticks,1 · 9 or developmental milestones. 5• 16- 18 A
is a woefully inadequate substitute for pincers. L0· 12 This reconstruction, digit associated with a transradial de-
the hand, witl1 its extraordinary dex- however, results in a rather uncos- ficiency should be preserved because
terity and versatility. By virtue of its metic appearance and ilius is rarely it may assist in grip function .
sensory feedback, tl1e hand can assess performed in most Western countries The classic indication for ilie
the physical properties of an object in spite of the excellent results Krukenberg procedure is in a person
such as its shape, size, surface texture, achieved in selected patients. 13 - t 5 A witl1 a bilateral transradiaJ amputa-
consistency, compressibility, and well-trained amputee who has had tion who was blinded in the same in-
weight. In darkness, the hand can pa1·- the Krukenberg procedure can typi- cident, usually the premature detona-
tially substitute for tlie eyes and can cally perform most activities of daily tion of an explosive device such as a
also provide a form of nonverbal living without a prosiliesis. Even after hand grenade. The procedure often
communication . Thus, in addition to the procedure, the amputee retains results in excellent restoration of a
enabling an individual to perform the the same choices for prostheses as any powerful and sensitive grip, 19· 24 but
essential activities of daily living, the other transradial amputee. Voca- despite these undisputed functional
hand may also serve as "eyes" for the tional, social, or cosmetic reasons may advantages, recommending tlie oper-
blind and "tongue" for the mute. ation for every transradial amputee
affect ilie decision to use a prosthesis.
Amputation of one hand is a ma- may be unrealistic because of the re-
jor impairment but one to which an sulting unnatural appearance. The
individual can readily adapt, provided Indications and Krukenberg operation should, tliere-
that the remaining upper limb is in- Contraindications fore, be undertaken only in a select
tact. Bilateral upper limb amputation group of highly motivated individu-
is a significantly greater loss, however. The Krukenberg procedure can be als. Candidates for the procedure may
And if bilateral amputation is accom- performed on transradial residual have either bilateral or unilateral
panied by blindness, ilie situation is limbs iliat result from an1putations transradial amputation, and they
initially overwhelming. The blind bi- from many causes. The most com- should be informed of the advantages
lateral upper limb amputee will be mon traumatic causes of transrad.ial and limitations of ilie procedure. 25 - 29
dependent on others for even the amputation include crush injuries In the unilateral transradial amputee,
most basic activities of daily living. that occur in traffic accidents, cutting the reconstructed limb will greatly
In 1916, Hermann Krukenberg, •-3 or crushing injuries caused by unpro- augment the function of the normal
a German army surgeon during tected machinery, frostbite, electrical limb by acting as an assistive "hand."
World War I, introduced bis recon- burns, and injuries caused by explo- The Krukenberg procedure is of
structive procedure for transradial sive devices. The Krukenberg opera- particular importance in countries
amputees, which was used extensively tion is often used to address the types where prosthetic services are nonex-
for boili wounded soldiers and civil- of injuries inflkted by war.9 •12 istent and/or the cost of a prosthesis

h
ual limb into sensate, m uscle-

powered radial and ulnar p incers,
th us creating a unique form of pre-
hension.
Skin Incision
U nder tourniquet control, the anterior
skin incision begins at a point
8 cm distal to the elbow crease and
2.5 to 3.0 cm lateral to the midaxial
line. A short extension is made proxi-
m ally and medially at an angle of 45°
for 2.5 cm. Returning to the starting
poi nt, the incision is continued dis-
tally to the midaxial point at the end of
the residual limb. This offset L-shaped
incision results in an ulnar flap that is
larger than the radial flap. A similar
Figure 2 lntraoperative photograph
showing myodesis attachment of exten-
but reversed posterior forearm inci-
sion is then made, resulting in a larger Fi
sor and f lexor groups. The L arm of t he
Figure 1 Orientation of t he fasciocuta ne-
offset radial flap (Figure 1). Both flaps fc
incision has been draw n on t he skin but
ous f laps for the Krukenberg procedure. a1
has not been incised at t his stage of t he are raised with their underlying fascia.
The solid line depicts the ant eri or offset cc
procedure. Note the wide passive separa-
L-shaped incision, and the dotted line de-
tion of the radius and ulna required for Muscle Management
picts t he reversed posterior incision.
f unctional pincer grasp.
The forearm m uscles that power the
wrist and fingers are blu ntly dissected
is prohibitive. This combination of
circumstances was seen during the Preoperative Care into radial and ulnar groups, begin-
ning proximally and conti nui ng to
civil war in Sierra Leone, where the Because of the unique cosmetic as- the end of the residual limb. Muscles
rebels chopped off the hands of cap- pects of the Krukenberg procedure, that insert onto the radius and ulna, p
tu red com batants and noncombatants sighted candidates, in particular, su ch as the pronator teres and anco- ti
alike. These persons were sent back to should have the opportunity to meet ne us, are not disturbed. Separntion of V;
their villages unable to care for them- a successful Krukenberg amputee to the muscle groups exposes both the
selves. The rehabilitation team sur- 0
assess the dexterity and versatility of anterior and posterior surfaces of the
geons working with these victims the prehensile rays for various tasks. ti
interosseous membrane. The mem-
opted for the Krukenberg procedure At the same time, the candidate can p
brane is divided along its ulnar at-
as the long-term solution. 12 •30 After a discuss issues pertaining to the ap- ti
tachment, taking care to preserve the
series of successful Krukenberg oper- pearance of the limb(s) with an e..xpe- interosseous vascular bu ndle. Th is in-
ations in the 1980s, Bangladesh issued r ienced user.31 - 36 If a Krukenberg am- tc
cision is extended proximally to an t}
a commem orative postal stamp show- p utee is not locally available, various extent that provides 12 cm of passive
ing an individual who had been fo rms of electronic media can be used e:
separation between the tips of the ra-
treated with bilateral Kru kenberg so that the candidate can meet a "vir- ti
dius and ulna durin g the surgical pro-
proced ures, writing with his residual tual" Kruke nberg user.
u
cedure (Figure 2) .
limbs. e,
Careful preoperative consideration
The Krukenberg procedure is con- of these issues by the surgical candi- Nerve Management s
traindicated in transradial amputees d ate should lead to easier acceptance The median nerve, under slight trac-
yo unger th an 2 years of age, in the ex- A
of the final appearance of the limb. tion, is ligated a nd divided where it
SI
trem ely old who are otherwise depen- Preoperative care should also include emerges from the pronator teres. The
dent on others, and in individuals exercises to improve the range of mo- b
ulnar nerve is sim ilarly divided under ,,..
who can not accept the appearance of tion and strength of both the recon- traction so that its end retracts into
the modified residual limb. T he oper- structed and intact upper limbs.
8
the proximal m uscle mass.
ation is also contrai ndicated when p
Vessel Management t,
there is a severe elbow joint contrac-
ture or when the residual limb will be
Surgical Technique Radial, ulnar, and interosseous vessels
p
0
too short for effective pincer fu11ction The Kr ukenberg operation is basically are separately ligated just proximal to
0
(ie, less than 10 cm in adults) .9 the conversion of a transradial resid- the proposed site of bone division.

Chapter 17: The Krukenberg Procedure 233
r Figure 3 Radiograph showing ideal uni- Figure 4 lntraoperative photograph of Figure 5 lntraoperative photograph
form muscular envelope covering radial complete coverage of both rays with op- showing a split-thickness skin graft cover-
s and ulnar rays, which was achieved with posing sensate skin, which was achieved ing the muscle mass when complete pri-
I. complete primary skin closure. without muscle debulking. mary closure is not possible without mus-
cle debulking.
e Bone Management covers the web of the pincer with nor-

d m al skin but also prevents fut ure scar- nator, flexor carpi ulnaris, and bra-
To create effective pincers, the radius
I- ring between the rays. The offset inci- chioradialis, resulting in an alm ost
and ulna must be of equal length. T he
0 sions result in normally sensate subcutaneous radius and u lna. 6 ' 22•44
bones are marked at a point 18 to
!S opposing skin in the d istal one third Based on experience at the Artificial
20 cm distal to the elbow crease. The
3, of the radial and ulnar rays, which is Limb Centre at Pune, India, with
periosteum is incised circumferen-
)- crucial for optimal utility of the pin- more than 500 Krukenberg proce-
tially 2 cm distal to this mark and ele-
)f cers (Figure 4). The wound is closed dures during the past 50 years, a split-
vated as a sleeve to the proposed level
ie with a drain at the web of the newly thickness graft is recommended
of bone division. T he bones are cut,
1e formed pincers. A number of varia- rather than muscle debuJki11g because
the edges are filed smooth, and the
1- tions in skin closu re have been advo- of the potential for skin necrosis or
periosteal tubes are snugly closed over
t- cated to achieve complete primary bone n ecrosis when enveloping mus-
the bone ends. The previously sepa-
1e coverage of the radial and ulnar rays cles are excised. If primary skin clo-
rated muscle groups are sewn securely
:l- with sensate skin. Krukenberg advo- sure on the radial or ulnar ray is not
to the periosteal sleeves at the tips of cated the use of a U-shaped midline
U1 possible, a split-thickness skin graft is
their respective rays. T his myodesis is incision. 1' 37 Methods that replaced
ve used to cover the exposed muscle
essential for the functional stability of this app roach were derived from the
a- mass (Figure 5).
these m uscles and should result in a principles of plastic sw-gery. These
o·
uniform muscle envelope enclosi ng include an offset incision with either
each bone (Figure 3). a proximal V- or L-shaped extension, Special
Skin Closure
which helps to cover the newly Considerations
!C- fo rmed web of the forceps, or an
it After releasing the tourniquet and en- S-shaped incision. 12' 17 •29 •38 "4 1 Some Other newer variations of the
he suring hemostasis, the skin is closed, have advocated a special inverted Krukenberg procedure include the
ler begim1ing at the proximal end of the L-shaped incision at the distal end to adjuvant use of wire fixators such as
1to wound . Because the incisions began ensure normally sensate skin in oppo- the Ilizarov ring mechanism or Joshi's
8 cm distal to the elbow crease, a sition at the tips. 11' 29' 42 ' 43 To facilitate external stabilization system (JESS)
Proximal web of soft tissue is majn- primary coverage of the rays and to axial fixator to lengthen a very short
tained. The L-shaped skin flaps can be avoid the need for a split-thickness transradial residual limb. A fixator
els passed between the radius and ul na skin graft, muscle debulkin g has been may also be used to keep the radius
to over the pronator teres and sutured advocated , even to the extent of re- and ulna distracted during the post-
over the web. This technique not only taining only the pronator teres, supi- operative period. Skin coverage for

m,
Figure 6 A, The postoperative dressing after a Krukenberg procedure (right resid ual Figure 7 AP and lateral radiographs
limb). The rad ial and ulnar rays are dressed individually and separated as widely as pos- showing distal bone necrosis of both th e
sible with bulky wool or gauze. In this photo, the patient was preoperative for a left radius and ulna after extensive muscle
Krukenberg procedure. B, Postoperative photograph of a similar patient w ith healed re- debulking to achieve primary closure.
sidual limbs after the Krukenberg procedure.
the lengthened bones can be achieved recommended, depending on the sis. Reanchoring the muscle sling over
by the staged use of tissue expanders, cond ition of the rays. Sutures are gen- the bone tips corrects this problem.
which provides primary closure with erally removed 12 to 14 days postop-
sensate skin without the use of a split- eratively. The drain from the base of
thickness graft.45 the pincers is removed after 48 hours
Reha bi I itation
The Krukenberg procedure can be without disturbing the main dressing. Immediately after removal of the su-
undertaken in children as young as 2 tures 12 to 14 days postoperatively,
years of age. Care is taken to avoid physical training of the forearm mus-
any injury to the distal physes, if Postoperative cles is initiated. The amputee is
present, for young patients with con- Comp I ications taught to open and close the newly
genital limb deficiency because major As with any other amputation, intra- bifid foreai-m to function as a pair of
upper limb growth occurs at the ta
operative damage to vessels or skin pincers. The muscles that facilitate
wrist. In adults with a shorter transra- af
closure under tension may result in opening of the pincers are those
dial residual limb, the length of the d1
flap necrosis. Subsequent manage- aligned on the lateral side of the ra-
base of the pincers can be reduced to dius (brachioradialis, extensor carpi
ment depends on the degree of necro- of
6 cm instead of the ideal 8 cm. An- radialis longus and brevis, radial por-
sis. If the necrosis is superficial and b(
other option is to reduce the length tion of the extensor digitorum com-
small in area, debridement may suf- it,
from the web to the distal end to 8 to munis, and biceps) and those on the
fice. If a large area is necrotic, a split- fo
10 cm, instead of the ideal 12 cm.
thickness graft may be necessary. If medial side of the ulna (flexor carpi r.a
necrosis of a bone tip occurs, waiting ulnaris, the ulnar part of the digi- tr,
Immediate for 2 to 3 weeks is recommended to tornm sublimis, the brachialis, and tic
allow demarcation of the sequestrum, the anconeus). The muscles that facil- in
Postoperative itate closing of the pincers are on the
which can then be excised (Figure 7) . in
Management A length disparity of more than 2 cm medial side of the radius (pronator n,
An important part of immediate between the radial and ulnar rays re- teres, supinator, flexor carpi radialis, si,
postoperative management is the sep- quires reshaping to equalize length. If the radial aspect of the flexor digi- th
arate dressing of the radial and uL1ar the muscles slip off the tip of the rays, torum sublimis, and palmaris longus) lll
rays with care to keep them as widely the function of the pincers will be se- and those on the lateral side of the
distracted as possible, using wool or riously compromised. This complica- ulna (extensor carpi ulnaris, ulnar
gauze as a spacer (Figure 6). The first tion results from either insecui-e an- part of the extensor digitorum com- is
choring of the periosteal tube over munis, and triceps). Evaluations, in- ft,
dressing change is done 4 or 5 days
postoperatively; subsequent dressing the radial and ulnar tips, or from an cluding the use of electromyography, ti1
n,
changes at intervals of 2 to 3 days are unbalanced, poorly anchored myode- have been used to describe the de-

Figure 8 Functional independence in se lf-care achieved by a bilateral Krukenberg amputee. A, Combing hair. B, Donning sock. C, Re-
moving bank notes from a wallet.
r,
Figure 9 Functional independence in work-related activities. A, Signing a document. B, An adaptive device for fine prehension. C, Us-
.S ing a computer keyboard and telephone .
y
>f
tailed muscle action in residual limbs to open and close the bifid forearm lates into an opportunity for indepen-
:e
after the Krukenberg proce- allows the patient to reproduce many dent living with renewed vocational
;e dure. s,9,29,44 functions of the hand (Figme 8). The options. The Krukenberg procedure
1-
Initiatjon of early physical training end result is an individual who can be need not be limited to use in blind,
)i
of the forearm musc;les is important totally independent, even when per- bilateral transradial amputees. This
r-
because of the somatosensory plastic- forming precision work such as procedure can be undertaken in any
1-
ity of the brain. 46 Initially, training threading a needle or participating in well-motivated, normally sighted bi-
1e
focuses on passive movement of the vocational activities, including han- lateral or even unilateral transradial
pi rays. Active exercises are gradually in- dling a phone or computer (Figure 9). amputee with exceUent results. The
troduced. Throughout the rehabilita- Individuals who are blind can learn resultant bifid forearm may not be
tion program, the opening and clos- the Braille alphabet.49 cosmetically acceptable to some am-
ing action should be performed only putees, which is a relative contraindi-
he in the sagittal plane to avoid any pro- cation despite its functional utility.
or nation and supination so that preci-
Summary The procedure is an important option
is, sion in grasping is encouraged from The loss of one band is a major im- for transradial amputees residing in a
~- the beginning.6 •28•47•48 Electrical stim- pairment, but independence is much country that has rudimentary or non-
is) ulation of muscles can also be quite more difficult to achieve with the loss existent services to provide prosthe-
he useful in rehabilitating the muscles. of both hands, especially when associ- ses.
tar The action of opening and closing ated with blindness. The Krukenberg A Krukenberg procedure does not
n- is gradually enhanced by increasing procedure converts the transradial re- alter the amputee's choice of a pros-
Jl- the amount of opening between the sidual limb to a pair of pincers, which thesis. Prostheses can be prescribed as
hy, tips and by strengthen ing the relevant functions as an efficient, sensate for any other transradiaJ amputee,
ie- muscle groups. An improved ability grasping organ. This in turn trans- ranging from a cosmetic prosthesis to

236 Section II: Th e Upper Lim b
a conventional transradial prosthesis of a pinch through transfer of a single tion: A current alternative to the
or a myoelectric prosthesis, depend- toe: Survey on five cases. Ann Chir Krukenberg operation. Handchir
ing on the intended use. 18 •50 • 53 If a Main 1989;8:207-216. Mikrochir Plast Chir 1985;17:92-97. 44
prosthesis is used, additional rehabili- 16. Harrison SH, Mayou B: Bilateral 29. Marquardt E, Martini AK:
tative training under the guida nce of Krukenberg operations in a young Krukenberg-plasty in the E. Mar-
child. Br J Plast Surg 1977;30: l 71-173. quardt modification. Handchir 45
an occupational therapist can be
17. Swanson AB, Swanson GD: The Mikrochir Plast Chir 1985;17: 117- 121.
helpful, depending on which prosthe-
Krukenberg procedure in the juvenile 30. De Smet L: Are there still indications
sis is available and/or required.
amputee. Clin Orthop 1980; 148:55-61. for the Krukenberg kineplasty? Report
18. Marquardt £: The multiple Jimb- of two patients. Chir Main 1999;18:
References deficient ch ild, in Bowker JH, Michael
132- 135.
]W (eds): Atlas of Limb Prosthetics: 31. Kreuz L: Die Herrichtung des Unter- 46
1. Krukenberg H: Ober die plastische
Surgical, Prosthetic, and Rehabilitation armsti.impfes zurn nati.irlichen Greif-
Umwertung von Amputations-
Principles, ed 2. Rosemont, lL, Ameri- arrn nach dem Verfahren von Kruken -
sttimpfen. Stuttgart, Germany, Enke-
can Academy of Orthopaedic Sur- be rgs. Zentralbl Chir 1944;7 I : 1170-
Verlag, 1917.
geons, 2002, pp 839-884. (Originally 1175.
2. Marquardt E: Die Krukenberg-Plastik:
published by Mosby-Year Book, 1992.) 32. Thomsen W: Diskussionsbeitrag zum
Origi.nalmethode und Modifikation
19. Colp R: Abstract: Krukenberg amputa- Thema Krukenberg-Plastik. Verh Dstch
fiir bli nde Ohnhander. Beschaftigungs-
tion. Ann Surg I 933;97:277-279. Orthop Ges I 948;78:60-61.
therapie und Rehab 1978; 17:221 -225.
20. Bauer KH: Zum Problem der 33. Lischenewsky SM: Effectivitat der op-
3. Baumgartner R: lndikationssteUungen
Ohnhanderversorgung und zur Frage erativen plastichen Spaltung von Un-
fur die Krukenberg-Greifuand auf-
terarmsti.i.mpfen. Orthop Tech 1978;29:
grund von Langzeitergebnissen. der operativen Behandlu ng insbeson-
l14-l16.
ZOrthop 1944;132:180- 184. dere des Krukenberg-Armes. Verh
Dtsch Orthop Ges Beilage Z Orthop 34. Lescoeur JE (ed): Amputes Des Mem-
4. Henry AK: An operation for making bres Superieurs: Leurs Vrais Problemes:
1948;78:5 l- 53.
the forearm prehensile after loss of a Chirurgie, Appareillage, Reeducation,
hand. Br J Surg 1928;16:188- 197. 21. Buck-Gramcko D: Hat sich die
Avenir. Paris, France, Maloine, 1979.
Krukenberg-Operation bewahrt u nd
5. Swanson AB: The Krukenberg proce- 35. Frantz CH, Aitken GT: Management
ist sie im Hinblick auf die modernen
dure in the juvenile amputee. f Bone of the juvenile ampu tee. Clin Orthop
Handprothcsen 11od1 ind iziert?
Joint Surg Am 1964;46: 1540-1548. 1959;14:30-49.
Ztschr-Orthop 1954;85:460-484.
6. Gu YD, Zhang LY, Zheng YL: lntro- 36. Song R: Experiences with the Kruken -
22. Nathan PA, Trung NB: The Kruken -
duction of a modified Krukenberg berg plastic operation. Clin Plast Surg
berg operation: A modified technique
operation. Plast Reconstr Surg 1996;97: 1982;9: 79-84.
avoiding skin grafts. J Hand Surg Am
222-226. 37. Krukenberg H: Erfahrungen mit der
1977;2:127-130.
7. Editorial: Krukenberg's chopsticks. Krukenberg-Hand. Arch Klin Chir
23. Mathur BP, Narang IC, Piplani CL,
BM! 1978;1:129. 1931 ;165: 191 -201.
Majid MA: Rehabilitation of the bilat-
8. PoweU HD: Letter: Krukenberg's chop- 38. Squires BT: Note on two cases of
eral below-elbow amputee by the
sticks. BMJ 1978; l :51 l. Krukenberg procedure. Prosther Orthot Krukenberg's operation. Br J Surg
9. Garst RJ: The Krukenbe rg hand. Int 1981;5:135-140. 1937;25:464-466.
I Bone Joint Surg Br 1991 ;73:385-388. 24. Sinaki M, Dob)1ns JH, Kirn1unen JM: 39. Simon P: Modalitaten des wieder
IO. Colp R, Ransohoff NS: The Kruken- Krukenberg's kineplasty and rehabili- eingetretenen Hautgefiihlesauf Bauch-
berg stump. J Bone Joint Surg 1933; 15: tation in a blind, bilateral fuU-hand hautplastiken von Krukenberg-
439-443. ampu tee. Clin Orthop 1982;169:163- Greifarmen. Monatsschr Unfallheilkd
11. Tubiana R: Krukenberg's operation. 166. 1961 ;46A: 1540-1549.
Orthop Clin North Am 1981;12:819- 25. BunneU S: Contractures of the hand 40. Gosset J, Langlais F: Digitization of
826. from infections and injuries. J Bone the forearm: Indications, teclrnique,
12. lrmay F, Merzouga B, Vettorel D: The Joint Surg l 932;14:27-46. long term results. Ann Chir 1975;29:
Krukenberg procedure: A surgical op- 1073-1078.
26. Alldredge RH: The cineplastic method
tion for the treatment of double hand in upper-extremity amputations. 41. Loosli-Guignard RM, Verdan C:
amputees in Sierra Leone. Lancet 2000; J Bone Joint Surg Am I 948;30:359-3 73. Krukenberg's operation: Indications
356: I 072- 1075. and limitations. Ann Chir Main 1983;
27. De Santolo AR: A new approach to the
13. Kallio KE: Recent advances in Kruken- 2:154- 159.
use of the Krnkenberg procedure in
berg's operation. Acta Chir Scand 1948; unilateral wrist amputations: An origi- 42. Marquardt E, Martini AK: Amputa-
97:165-168. nal functional -cosmetic prosthesis. tio n surgery of the upper extremities.
14. Ritsila V, Kiv ilaakso R: Modification of Bull Hosp ft Dis Orthop Inst 1984;44: Z Orthop 1hre Crenzgeb 1979;117:622-
Krukenberg's kineplastic operation. 177- 187. 631.
Ann Chir Gynaecol l 976;65:338-341. 28. Vilkki SK: Free toe transfer to the fore- 43. Martin i AK: The Krukenberg plasty
15. Egloff DV, Cantero J: Reconstruction arm stump following wrist amputa- and the provision of additional pros-

.....
theses and technical aids. Z Orthop 47. Heyne S: Ergotherapie bei blinden Sl. Visuthikosol V, Wongbusarakwn S,
Ihre Grenzgeb 1983;121:196-202. Ohnhandern mit Krukenberg-Plastik. Navykam T, Kruavit A: The Kmken-
44. Zanoli R: Krukenberg-Putti Beschiiftigungstherapie und Rehab 1978; berg procedure in the bilateral ampu-
amputation-plasty. J Bone Joint Surg Br 17:227-234. tee after electrical burn. Ann Plast Surg
l 957;39:230-232. 1991;27:56-60.
48. Ryder RA: Occupational therapy for a
45. Stober R, Traub S: Modified patient with a b ilateral Krukenberg 52. Heger H, Millstein S, Hunter GA: Elec-
Krukenberg-plasty with cal1us distrac- amputation. Am J Occup Ther 1989;43: trically powered prostheses for the
tion of the stump and complete skin 689-691. adult with an upper limb amputation.
closure of both forearm branches. J Bone Joint Surg Br 1985;67:278-281.
49. Lob A: Krukenberg's plastic operation
Handchir Mikrochir P/ast Chir 1998;30: in peacetime. Hefte Unfallheilkd 1970;
53. Daisey R, Gomez W, Seitz WH Jr, Dick
325-329. HM, Hutnick G, Akden iz R: Myoelec-
105: 1-48.
46. Borsook D, Becerra L, Fishman S, et al: tric prosthetic replacement in the
50. Moberg E: Hand surgery and the de- upper-extremity amputee. Orthop Rev
Acute plasticity in the human soma-
velopment of hand prostheses. Scand J [989;18:697-702.
tosensory cortex follow ing ampu ta-
Plast Reconstr Surg 1975;9:227-230.
tion. Neuroreport 1998;9:1013- 1017.
:h
~=
11-
g
ch-
I:
IS
13;
ies.
ii-
y
os-

Elbow Disarticulation and
Transhumeral Amputation:
Surgical Management
Patrick Owens, MD
Introduction
The etiology of 90% of upper limb because of better long-term func- teotion of full humeraJ length pre-
amputations is trauma. Men sustain tional outcomes. 2 In adults, however, cludes the use of a prosthetic elbow.
fow· times as many amputations as less than 25% of patients regain func- In addition, the external hinge elbow
women, with most injuries occurring tional use of the limb,3 and some re- mechanisms that are available for dis-
in individuals age 20 to 40 years. 1 qu ire revision to a transradial ampu- articulation are less pleasing cosmeti-
FunctionaJ rehabilitation is especially tation to maximize functional use of cally.
important in these young patients. the limb. Major replantation above In children, t ranshumeral amputa-
Other causes of amputations include the level of the wrist carries signifi- tion results in a high incidence of
burns, malignant tumors, neurologic cant metabolic risks to the patient be- bony overgrowth that requires revi-
disorders, infections, congen ital de- cause of the volume of involved mus- sion; therefore, elbow disarticulation
formities, and peripheral vascular d is- cle.4 However, patients with sensation is the level of choice.7 The slowed hu-
ease. In the upper limb, vascular etiol- and some residual function in the re- meral growth that occurs after elbow
ogies of amputation are as common planted limb have better functional disarticulation will result in a hu-
in children as in adults because of outcomes than amputees with pros- meral length at maturity that aJlows
conditions such as fulminating menin- theses. 3
use of a prosthetic elbow while retain-
gococcemia and disseminated intra- ing the suspension and rotational
Level of Amputation
vascular coagulation. Although am- control benefits of an elbow disartic-
putation rates for malignant tumors Amputation should be performed at
ulation.8
in the upper limb have decreased wit h the most distal level possible that aJ-
SeveraJ issues arise with more
advances in limb salvage techniques, lows for control of the disease or is
proximal amputations. For effective
amputation is still sometimes re- consistent with the zone of injury.
Wound coverage is best achieved with control of the shoulder, the insertion
quired for t umor control. Amputa- of the deltoid must be retained. High
local skin flaps that aJlow for ade-
tion may also be necessary in patients proximal transhumeral amputation is
quate padding and closure. 1 Greater
with severe, nonreconstructable bra- preferable to shoulder disarticulation
residual limb length can often be pre-
chia! plexus injuries. cosmetically because it retains the
served by covering the wound with
skin grafts, free or abdominal flaps, or shoulder contour, but functionally,
General Surgical flaps from the amputated parts.5 the two levels are similar. When am-
Ilizarov bone lengthening techniques putations are performed at the level
Considerations of the surgical neck, abduction con-
have been described6 but are rarely
Replantat ion indicated with use of modern pros- tractures can occur; therefore, pri-
Because of advances in microvascular thetic sockets. 1 mary shoulder arthrodesis can be
techniques, replantation has been a Controversy exists over whether to considered at this level. 1 Prosthetic
viable option in traumatic upper limb perform a long transhumeral ampu- suspension is more easily accom-
amputations since the first successful tation or an elbow disarticulation. plished with retention of the proximal
upper limb repJantation in 1962. The disarticuJation allows enhanced humerus, and function is somewhat
Children are candidates for replanta- suspension and rotationaJ control of improved for both the myoelectric
tion at nearly any level of amputation the prosthesis. In adults, however, re- and body-powered prostheses.

Transhumeral
Amputation
Every attempt should be made to re-
( tain maximum possible residual limb

length. The principles of trans-
humeral amputation are the same as
for elbow disarticulation. The perios-
teum should be incised sharply to re-
duce the risk of overgrowth, and the
long posterior flap should include the
triceps muscle. At the time of wound
closure, the triceps and the biceps
should be secured to the humerus us-
ing transosseous sutures (myodesis).
This will ensure adequate padding for
the distal bone end and stable muscles
for myoelectr.ic sensors. For amputa-
tions through the surgical neck,
Figure 2 Marquardt angulation osteot·
omy of t ranshumeral amputation show-
shoulder arthrodesis should be per-
ing flexion of t he distal fragment over formed primarily.
the anterior cortical fulcrum. An incom- For patients with long or mid-
plete posterior osteotomy was performed length humeral segments, an angula- Fi
Figure 1 Mature traumatic elbow disar- t o minimize f urther loss of length. The tion osteotomy, as described by Mar- b:
prosthesis socket can be f itted around (f
ticulation allowed successful prosthetic
the anterior bony prominence to en-
qmu-dt and Neff, 10 facilitates the q,
fitting. (Courtesy of John H. Bowker,
hance suspension and rotational cont rol fitting and function of the prosthesis 0,
MO.)
of the prosthesis. (Reproduced with per- by providing both better suspension 1:
Technique mission from Marquardt E, Neff G: The and rotational control. The unique
angu/ation osteotomy of above-elbow
The use of a pneumatic tourniquet abbreviated socket suspended from
stumps. Clin Orthop 1974;104:232-238.)
is recommended for more distal am- the angled humeral segment frees the
shoulder joint, facilitating overhead
putations to aid in visualization of
Elbow reaching and the substitution of
major neurovascular structures. Ex-
shoulder rotation for wrist rotation. A
sanguination is accomplished by ele- Disarticulation 70° angle with respect to the humeral
vation of the limb for 2 to 3 min utes.
After the skin flaps are created, the shaft, apex dorsal, is desirable. Neuse[
Double ligation of the major arteries
flexor and extensor muscle origins are and associates 11 reported straighten-
should be performed along with liga-
removed sharply from the epi- ing of the humerus within 2 years fol-
tion of the larger collateral vessels. lowing the osteotomy in nearly two
The tourniquet should always be de- condyles. The nerves and blood ves-
sels are isolated and treated as de- th irds of ch ildren. In contrast, the
flated prior to wound closure to en- adults showed no loss of angulation.
sure hemostasis. scribed above. The biceps, brachialis,
In children, the osteotomy is made
The median, ulnar, radial, and me- and triceps tendons should be
approximately at the junction of the
dial and lateral antebrachiaJ cutane- transected, followed by division of the
middle and distal thirds of the hu-
ous nerves should be identified, capsular and ligamentous attach-
merus. An anterior closing wedge os-
transected under modest tension, and ments. An oscillating saw may be used teotomy is performed, leaving the pos-
allowed to retract under proximal soft to remove the prominences of the terior periosteum intact. The bone
tissue several centimeters proximal to medial and lateral epicondyles and fragments are secured with a Kirsch-
the bone ends. This increases the like- the distal humerus. This maintains ner wire. If removal of a wedge results
lihood that any neuroma formation the expanded end of the humerus and in unacceptable shortening, an incom-
will occur in a well-protected area. 9 facilita tes better rotational control of plete posterior osteotomy is per-
The posterior flap should be longer the prosthesis while red ucing the formed, and the bone is flexed over the
than the anterior flap if possible; this chance of skin pressure ulcers related anterior cortical fulcrum to the de-
allows closure of the wound away to the prominent epicondyles. The bi- sired angulation and fixed (Figure 2).
from the distal end of the residual ceps and triceps should be attached at Local periosteal flaps are used to cover
limb. Alternatively, equal anterior and physiologic tension to the distal por- the posterior bony defect, and a cast is
posterior flaps can be used. tion of the residual limb (Figure 1). worn for 5 to 6 weeks postoperatively.

Chapter 18: Elbow Disarticulation and Transhumeral Amputation: Surgical Management 24 1
In adults, an anterior closing 5. Weinberg MJ, Al-Qattan MM, Ma-

wedge osteotomy is made 5 to 7 cm honey J: "Spare part" forearm free
proximal to the bone ends (Figure 3). flaps har vested from the amputated
Osteosynthesis is obtained with a lag lim b for coverage of amputation
screw. With good fixation, casting stumps. I Hand Surg Br 1997;22:
generally is not required fo r immobi- 615-619.
lization, although it can be used to 6. Me rtens P, La m mens J: Short amp uta-
control postoperative swelling. tion stump lengthening with the
Ilizarov method: Risks versus benefits.
Acta Orthop Belg 2001;67:274-278.
References 7. Aitken GT: Su rgical amputation in
l. Baumgartner R: Upper extremity am- children. J Bone Joint Surg Am 1963;45:
putations, in DuParc (ed): Surgical 1735- 1741.
Techniques in Orthopaedics and Trau- 8. Abraham E, Pellicore RJ, Hamilton
matology. O rlando, FL, Harcourt Inter- RC, Hallman BW, Ghosh L: Stump
national, 2003, vo l 4. overgrowth in juvenile amputees.
r
s 2. Jaeger SH, Tsai TM, Kleinert HE: Up- I Pediatr Orthop 1986;6:66-71.
per extremity replanta tion in child ren.
9. Wh ipple RR, Unsell RS: Treatment of
,, Orthop Clin North Am 1981;12:897-
painful neuromas. Orthop Clin North
907.
Am 1988;19: 175- 185.
3. Graham B, Adkins P, Tsai TM, Firrell J,
10. Marquardt E, Neff G: The angulation
Breidenbach WC: Major replantation
1- osteotomy of above-elbow stumps.
versus revision amp utation and pros-
I- Figure 3 Marquardt angulation achieved Clin Orthop 1974;104:232-238.
thetic fitting in the upper extremity: A
r- by anterior closing wedge osteotomy.
late functional o utcomes study. JHand 11. Neuse! E, Tra ub M, Blasius K, Mar-
(Reproduced with permission from Mar-
1e SurgAm 1998;23:783-791. quardt E: Results of humeral stump
quardt E, Neff G: The angulation osteot-
is omy of above-elbow stumps. Clin Ort h op 4. Wood MB, Cooney WP III: Above el- angu.lation osteotomy. Arch Orthop
,n 1974;104:232-238.) bow limb replantation: Functional Trauma Surg 1997;116:263-265.
1e results. J Hand Surg Am 1986; 11 :682-
Ill 687.
1e
id
of
A
:al
;el
n-
)1-
NO
he
).
1de
:he
lU-
OS-
os·
me
ch·
Jlts
,m-
,er-
the
de·
2).
>ver
st is
rely.

Elbow Disarticulation and
Transhumeral Amputation:
Wayne K. Daly, CPO, LPO
Introduction
Successful patient rehabilitation and noted above that influence the suc- verage to control the prosthesis. Re-
effective functional use of a trans- cessful use of the prosthesis. A careful sidual limb length wilJ also affect the
humeral or elbow disarticulation analysis of tl1e patient's physical capa- choice of elbow components. In
prosthesis depend on many factors. bility and appropriate prosthetic op- adults, humeral transection 10 cm
Key elements that influence prosthetic tions will reduce the long-term cost of above the olecranon tip enables use of
outcome include (l) the lever arm care while increasing the functional all available prosthetic components,
length of the remaining bone, (2) the use of the prosthesis. Although a including externally powered alterna-
quality and nature of the skin and prosthesis is not absolutely necessary tives. Excess residual limb length from
soft-tissue coverage of the limb and for an amputee to function and many redundant tissue is functionally use-
torso, (3) muscle function and tone in activities can be accomplished with less and serves on ly to complicate the
the residual limb, (4) pain control in one hand in the case of a unilateral prostl1etic fitting. Copious redtmdant
the residual Umb, (5) joint range of loss, there are solid reasons for con- tissue makes donning the prosthesis
motion and strength of ilie residual sidering a suitable prosthesis. Clinical much more difficult, often compro-
limb and upper body, and (6) rehabil- experience and recent studies suggest mises cosmesis, and may preclude the
itation support, ie, the availability and that overuse problems with the re- use of typical elbow components.
skill of psychological, rehabilitation mai ning hand and arm may develop Soft-tissue coverage also affects
therapy, and prosthetic practitioners. in as many as 50% of upper limb am- prosthetic function because a painful
All of these elements must be consid - putees.2·3 Active use of a prosthesis is residual limb will limit the force that
ered carefully to achieve the best pos- believed to reduce this risk. A pros- the amputee can comfortably generate
sible prosthetic outcome. Most stud- thesis also facilitates ilie many tasks to control the prosthesis. Adherent,
ies have shown a long-term rate of requiring bimanual capabilities. scarred distal tissue shortens the effec-
prosilietic wear for transhumeral :and tive lever arm available to generate
elbow disarticulation amputees of less control forces nearly as much as if the
than 50%. 1 Although there may be
Bone Length bone was transected at a higher level.
many reasons for these findings, these The length of the remaining bone is Amputation proximal to the del-
levels of loss clearly present a signifi- crucial to prosiliesis design and func- toid insertion will render active place-
cant rehabilitation challenge. Careful tion. Altl10ugh trauma situations may ment of the prosthesis in space
surgery, evaluation, prosthetic fitting, limfr the surgical options, the best impossible for the amputee. Biome-
and therapy are all crucial to success- possible resid ual limb should be pro- chanically, patients with very short
ful outcome and op timal prosthetic vided for future rehabilitation. In the humeral remnants function as if
function. Each of these factors and case of elective or revision surgery, they have a shoulder disarticulation.
appropriate prosilietic options are extra care in planning for the most Lengthenings using the Ilizarov tech-
discussed in this chapter. functional residual limb can facilitate nique or fibular bone grafts have
the best possible outcome. 4 The proven successful in improving pros-
length of the bone is a primary con- thetic function in some amputees.5•6
Pat ient Evaluation sideration in the biomechanics of the The elbow disarticulation level of-
The patient should be evaluated care- artificial arm. In general, a longer hu- fers several functional advantages that
fully to assess the numerous elemen ts meral segment will provide more le- are especially valuable for tl1e bilateral

prosthesis, optimize myoelectric sig-

nals, and are believed to prevent the
pain and marked atrophy that may
develop over time with unstabilized
muscle. Brachial plexus injuries may
\ \ benefit from a shoulder fusion to
eliminate subluxation, extend the
Figure 1 Osteotomy procedure scapular lever arm, and eliminate the
used by de Luccia and Marino7 need to cover much of the torso to
to reduce the humeral length
stabilize the prosthesis. Careful con-
of an elbow disarticulation by
3 cm. A, Location of cut lines on sideration of the fusion angle and hu-
the humerus. B, Reduced length meral length facilitate a prosthetic fit-
w ith remova l of the bone seg- ting of the brachia} plexus amputee. 10
A B ment.
Joint Range of
upper limb amputee who must use tees to provide active humeral rota-
Motion
the residual limb for self-care. The tion without the bulk of the elbow Joint range of motion is significant to
hmneral condyles can provide body- disarticulation epicondyles.8 •9 prosthetic function because restric-
controlled, active humeral rotation of tion of motion will reduce the capa-
the prosthesis. This significantly in- bility of the prosthesis. Restricted
creases the active work envelope of
Quality of Skin and
motion of either shoulder will reduce
the prosthesis compared with the pas- Soft Tissue available body control motions and
sive hmneral rotation offered by the The quality of the skin and soft-tissue may require externally powered com-
typical prosthetic elbow mechanism coverage of the bone are important ponents to provide adequate func-
used for transhumeral and higher lev-
for both the function and comfort of tion. Although full joint range is not
els. An elbow disarticulation also may the prosthesis. If the bone is not well always required for prosthetic use,
be useful in children because theepiph- protected, it will be difficult for the biscapular motion and humeral range
ysis is preserved, thus preventing amputee to maintain the precise fit of motion on the amputated side are
bony overgrowth and maintaining
necessary to prevent excessive pres- especially critical to the function of
growth potential. The elbow disartic-
sure and pain in the residual limb. the prosthesis. Frozen shoulder syn-
ulation level requires the use of small
Scar tissue and skin grafts should be drome and subluxation must be pre-
locking joints located adjacent to the
placed away from the cut end of the vented whenever possible and treated
humeral epicondyles, external to the
bone and away from the axilla when- aggressively when present.
socket, reducing the durability and
ever possible. In a prostl1esis, the an-
cosmesis of the prosthesis. Some at-
terior, lateral, and axillary surfaces of
tempts have been ma.de to reduce the
length problem of this level by using a
the residual limb are major pressure- Rehabilitation
and force-bearing areas; any painful Support
length osteotomy to shorten the hu-
or severely scarred tissue in these ar-
merus while maintaining the epi- Psychological counseling is often over-
eas will complicate prosthetic fitting.
condyles for rotation control and sus- looked in the care of the amputee, but
Burns and scar tissue on the torso will
pension7 (Figure 1). This technique it can be very helpful with pain control
also complicate the harness design
permits the use of standard prosthetic
and may require a self-suspending, and emotional adj ustment. A well-
components while maintaining the
externally powered prosthesis to pre- trained multidisciplinary team facili-
functional advantages of the elbow
vent recurrent skin damage. tates successful prosthetic rehabilita-
disarticulation. In essence, this
tion, especially in bilateral amputees.
method creates a foreshortened resid-
Peer visitation and support groups
ual limb, substantially improving cos- Muscle Strength and may also be helpful during the post-
mesis. The final result is analogous to
the reduced final growth length of a
Tone amputation adjustment period. Other
pediatric elbow disarticulation. Be- Muscle function and strength ulti- important considerations include
cause voluntary control of humeral mately determine how functional tl1e prompt prosthetic fitting; care in de-
rotation is so helpful in achieving in- prosthesis will be. Muscles that have signing and creating the prosthesis;
dependence, an angulation osteotomy been surgically stabilized with myode- and structured follow-up, training,
has been proposed for bilateral ampu- sis provide superior control of the and therapy.

Chapter 19: Elbow Disarticulation and Transhumeral Amputation: Prosthetic Management 245
0
A B c D
Figure 2 A poorly fitting socket (A and B) t ends to gap w hen the arm is abducted or flexed. A more intimately contoured socket
(C and D) offers better contact and control.
Prosthesis Design powered components. The major

0
Socket Design drnwback of any harness is the inevi-
table restriction in range of motion,
l- The socket design will vary with the
chafing from the straps, and the po-
:d length of the residual limb and the
tential for pressure on the contralat-
:e suspension method chosen. The most
eral ax:illa, which can lead to nerve
1d common transhumeral socket designs
damage in the opposite arm over
1- are rigid fiber-reinforced plastic lami- time. 2
c- nation or a flexible thermoplastic
The suction socket provides excel-
ot socket with rigid open frame. Special
lent suspension and control but re-
:e, care in shaping the proximal trim-
quires very stable limb volume and
lines is necessary to provide rotational
ge sufficient skill to apply the prosthesis
stability and suspension, particularly
re with a "pull-in" sock. Suction suspen-
as the residual limb becomes shorter
of sion is often used in conjunction with
(Figure 2). Flexible open-frame sock-
n- externally powered components to
ets provide a softer interface for the
:e- eliminate or reduce the amount of
skin and are reported to be cooler and
ed harnessing necessary.
more comfortable for the amputee 11
The roll-on liner can also be used
(Figure 3).
to suspend the prosthesis and will ac-
When fully formed condyles are
commodate mild to moderate volume
present, the width and length of these
changes in the limb. This system has
structures must be accommodated in
proved successful with both body-
the socket. Three common designs in-
powered and externally powered
er- clude the fenestrated, screw-in, and
components. 12 • 14
)Ut flexible wall socket types discussed
below. With elbow disarticulations, Elbow disarticulation prostheses
rol
the socket provides rotational control typically rely on the epicondyles for
ell-
and suspension from the oval shape at suspension, provided they are well-
:ili-
the end of the limb. shaped and not tender. The widest
ita-
portion of the condyles must pass
ees.
into the socket a nd then somehow be Figure 3 Posterior view of a flexible
ups Suspension Systems "locked" in place. Windowed or flexi- socket, rig id-frame transhumeral prosthe-
)St-
The prosthesis can be suspended by a ble wall sockets are often used to pro- sis w it h body-powered elbow.
:her harness, suction, a roll-on liner, ana- vide entry and suspension at this level
ude tomic contouring, or any combina- (Figure 4) . Some practitioners use a
de· tion of these methods. The traditional spiral groove or cut-out in the socket
esis; figure-of-8, chest strap, and shoulder to "screw" the epicondyles into the epicondyles will determine the best
ing, saddle harnesses provide suspension end of the socket (Figure 5). The design for the elbow disarticulation
as well as control of the body- shape and pressure tolerance of the level.

246 Section II: Th e Upp er Limb
\ I
1I
Figure 4 Elbow disarticulation prosthesis
with a removab le door for donning and
suspension. (Reproduced with permission Figure 6 Back view of one method for
from Otto Bock Prostesen -Kompendium: wrapping t he transhumeral residual limb
Prostesen f ur die obere Extremitat . Ber- in an elastic bandage.
lin, Germany, Schide & Schoen, 1976.)
needed later in rehabilitation. An em-

Stages of Care phasis on bi.manual activity will in-
Immediate/ Early crease the amputee's confidence and
capability with the prosthesis.
Management
After the prosthesis is delivered,
!
~
The cited advantages of immediate there should be a follow-up plan to
Figure 5 Elbow disarticulation socket us-
and early postsurgical prosthetic fit-
ting for lower limb amputees include
ing a spiral slot for donning and suspen-
sion by screwing t he epicondyles int o
maintain and refine long-term func-
tion. Modification of the harness or •c
control of edema and a reduction in
postamputation pain by contain ing
place. (Adapted with permission from
Bray JJ: Prosthetic Principles: Upper Ex-
tremity Amputations (Fabrication and Fit -
socket is common to accommodate
changes in the residual limb and to
•t
the residual limb in a rigid dressing. improve function by relocating cable
ting Principles). Los Angeles, CA; Pros-
These same factors apply to upper reaction points. Ongoing follow-up
thetics Orthotics Education Program,
limb loss. 15 The practical difficulty in University of California Press.) ensures that continued improvement
postoperative fitting of patients with to the prosthetic design will occur as
transhumeral amputation has been the amputee becomes more proficient
maintaining suspension of the cast as might pose. In selective cases, a prepa-
and contributes to attainment of the
residual limb volume decreases. This ratory prosthesis will provide fw1etion
best possible functional outcome.
has limited the use of postoperative while early limb atrophy takes place.
dressings for this group. There may be Actively managed early care is the Components
a psychological benefit to early fitting; foundation for later success, not sim- The selection of components will vary d,
some evidence exists that successful ply a time to wait for healing. depending on the character of the re- fie
prosthetic use is higher when the fit- sidual limb and the individual needs lo
Provision of the Prosthesis
ting is completed within a "golden pe- of the amputee. Harness design will d(
riod" of 30 days after su rgery. 15 The prosthesis should be provided in depend in large part on the body a
Once primary healing has oc- a timely manner, ideally with in 30 to shape and functional capabilities of w
curred, the limb must be shaped and 60 days after surgery, to increase the the amputee. The figure-of-8 harness h,
desensitized to prepare for the pros- likelihood of use. An evaluation pros- provides the greatest available excur- C2
thetic fitting. Shrinkers or elastic ban- thesis is often helpful to refine the de- sion but tends to create pressure 11]
dage wraps are helpful to shape the sign and desired functional perfor- problems on the contralateral ax:illa. Cl
soft tissue and reduce the size of the mance of the prosthesis, particularly The shoulder saddle and chest strap fu
limb in preparation for fitting (Figure for more complex cases such as bilat- design reduces axilla forces and pro- fr
6). Active joint range-of-motion exer- eral Joss or high-level amputation. vides better lifting capability but does A
cise and pain control are necessary Specialized training of amputees to not harness shoulder excursion of the si,
during this time. Prosthetic evaluation improve skill in using a prosthesis is contralateral side. Cl
and counseling should begin as soon important if they are to receive the The traditional body-powered te
as possible, both to answer patient fuU benefit of prosthetic use. This Jocking elbow with harness- n,
questions and to develop a clear plan training can be part of the physical controlled lock is generally preferred si
of care. Part of the plan will be deter- and occupational therapy of the early if the patient can operate it well. Lift
tl1
mining funding sources (eg, insurance healing phase, but special focus on assists or forearm-balancing designs
plans) an d any restrictions that they the use of the prosthesis is also should be added in most cases to re-

Chapter 19: Elbow Disarticulation and Transhumeral Amputation: Prosthetic Management 247
::\
l,
0
,r
:e
·o
le
Figure 7 Patient described in case study 1. A, Initial amputa-
.p
tion w ith excessive distal redundant tissue and lengt h. B, Fit-
1t ted as an elbow disarticulation because of the length of t he
'IS redundant t issue. C, After revision to remove excess t issue and
:it stabilize t he muscles. D, Fitted transhumeral prosthesis and
le figure-of-8 harness, ro ll-on suspension sleeve, and body-
powered elbow. E, Fitted with a roll-on sleeve, self-
suspending, myoelectrically controlled prosthesis.
ry duce the force required for elbow Biomechanics of Control electric or servo controls are now
e- flexion. A quick-disconnect wrist al- The function of a body-powered available that can provide propor-
ds lows the patient to exchange terminal prosthesis is completely dependent on tional speed and force control for
ill devices (TDs) more easily; otherwise, the amount of cable excw·sion created both elbows and TDs. It is quite com-
dy a lightweight constant-friction wrist by the patient. A rough measure of mon to use a body-powered elbow
of will suffice. Many patients prefer to available cable excursion can be made with a switch- or myoelectric-
!SS have both a hook and a hand TD be- controlled TD. This arrangement sim-
by placing a tape measure arotmd the
u:- cause they have different but comple- plifies harnessing while providing
sound axilla to the midpoint of the
ue mentary functions. If the available ex- quick elbow flexion plus force feed-
residual limb. The difference in tape
la. cursion is not sufficient to control a back through the harness. An elec-
length from shoulders at neutral posi-
ap fully body-powered prosthesis effec- tronic elbow and body-powered TD
tion to full bilateral shoulder protrac-
:o-
tively, then external power is required. tion and 45° of humeral flexion will offer similar advantages, except that
)eS
As a general rule, the shorter the re- approximate the maximum potential elbow motion is slower while TD
:he speed is more rapid. A prosthesis with
sidual limb, the more limited the ex- excmsion. For full body-powered
cursion available. Endoskeletal sys- control of the elbow and TD, roughly two or more powered components
red
tems for upper limb prostheses are 11.5 cm of cable excursion is needed. will be heavier and more costly than a
:SS-
not as durable as an exoskeletal de- If force or excursion is inadequate hybrid system that includes at least
red
sign, but they can restore body sym- for full body power, then external one body-powered component.
~ift
metry while minimizing weight and power is essential if the patient is to Switch and servo controls require only
511S
re- are well suited for passive prostheses. actively control the prosthesis. Myo- a light harness to activate the controls

7, C) . Two months later, the patient m

received a new prosthesis with a di
body-powered locking elbow and
chest strap to reduce harness pressure fire
on the opposite axilla. This prosthesis er
also included a roll-on suspension is
liner to fmther reduce the harness o,t
fo rces (Figure 7, D). Eleven months tic
after the injury, a new prosthesis was
prescribed to eliminate the continued
irritation from the harness and pro- s
vide a more powerful grip than the M
body-powered device permitted . Be-
cause the myoplasty resulted in good la
control of the residual limb muscles, vi
the patient received a myoelectrically r:a
controlled prosthesis with powered pl
elbow, hand, and hook (Figme 7, E). te
He now wears a prosthesis full tin1e, pl
interchanging body-powered and ex- tl1
ternally powered prostheses depend- h
ing on the activities being performed. pl
The patient underwent one additional Jll.C
Figure 8 Patient described in case study 2. A, Patient wearing a flexible wall socket with neuroma excision sinee this fitting, llj
chest strap suspension and body-powered elbow and hook. B, Patient wearing a special- reducing his pain sufficiently that he
q(I
purpose prosthesis w ith rol l-on sleeve suspension, nylon transfemoral knee unit used as was able to work full time while using
an elbow, and quick-disconnect wrist used for bicycling.
n,
the prosthesis.
tt
This case study illustrates that with
it
and can be considered if reliable myo- the distal tissues, which were painful ongoing follow up, and revision sur-
ft:
electric con trol is not available. when unsupported. Because of fund- gery when necessary, an initially mar-
ing delays, fitting could not begin un- ginal situation can be improved and
til l O weeks postoperatively, at which the functional capability of the pa-
Case Studies time the residual limb was well healed tient greatly increased. Prosthetic
Case Study 1 but the patient still had moderate follow-up care should be a continuing
A 24-year-old male laborer was in- process to provide the best possible
pain.
long-term functional outcome.
jured in a conveyer belt accident on The prosthesis (Figure 7, B) in-
the job. He sustained a severe crush cluded a total-con tact laminated Case Study 2
injury to his left arm that resulted in a socket with outside locking hinges (to
A 54-year-old man who was injured
transhwueral amputation. The limb accommodate the. excessive residual
in military action at age 21 years un-
was surgically closed but there was limb length ), a figure-of-8 harness,
derwent a left transhumeral amputa-
significant distal redundant tissue a11d and a voluntary opening hand and in- tion. He had been fitted with many
scarring from the skin trauma (Figure terchangeable voluntary opening alu- different prostheses over the decades
7, A). Glenohumeral and scapular minum split hook. After training with but now wears a flexible socket, rigid-
range of motion was good and shoul- a therapist, the patient could use the frame prosthesis with a chest strap
der strength was very good, but the prosthesis, but the pain in the residual harness. This configuration offers
residual limb measured 2.5 cm longer limb from neuromas and scar tissue good function and frees up the con-
than the opposite epicondyle length failed to resolve. Months later, the pa- tralateral shoulder for work activities
because of the redundant tissue. The tient elected to undergo revision sur- (Figure 8, A). He also has a prosthesis
patient was first seen for prosthetic gery to reduce the excessive distal tis- for cycling. This activity-specific
care 8 weeks after amputation, at sue, stabil ize the muscles, remove the prosthesis includes a roll-on suction
which time the residual limb was not scar tissue, and resect the painful neu- suspension sleeve, a nylon prosthetic
yet completely healed because of the romas. The surgeon removed 7.5 cm knee unit that serves as the elbow, and
amount of skin trauma. The patient of excess soft tissue from the distal a quick-disconnect wrist for safety
was provided with elastic shrinkers to end of the limb and performed a myo- (Figure 8, B). This design allows him
faci litate limb shaping and support plasty to stabilize the muscles (Figure to steer a bicycle while absorbing

'
I
Chapter 19: Elbow Disarticulation and Transhumeral Amputation: Prosthetic Managem ent 249
much of the vibration from the han- amputation and prosthetic limb fit- 9. Marq uardt VE: The multiple limb-
dlebars. ting. J Hand Surg Am 1994;19:836-839. deficien t child, in Atlas of Limb Pros-
Many upper limb amputees benefit 2. Jones LE, Davidson JH: Save that arm: thetics: Surgical, Prosthetic, and Rehabil-
from special-purpose designs. T h e A study of problems in the remaining itation Principles, ed 2. Rosemont, IL,
creative challenge fo r the prosthetist arm of unilateral upper limb ampu- American Academy of Orthopaedic
tees. Prosthet Ortliot Int 1999;23:55-58. Surgeons, 2002, pp 608-612. (Origi-
is to adapt components intended for
3. Reddy MP: Nerve entrapment syn- nally published by Mosby-Year Book,
other uses to create workable solu-
dromes in the up per extremity con- 1992.)
tions for specific needs.
tralateral to amputation. Arch Phys 10. Malone JM, Leal JM, Underwood J,
Med Rehabil 1984;65:24-26. Childers SJ: Brachia! plexus injury
Summary 4. Wood MR, Hunter GA, Millstein SG: management through upper limb am-
The value of revision surgery after putation with immediate postopera-
Many factors influence the s uccessful initial amputation of ru, upper or tive prosthesis. Arch Phys Med Rehabil
use of prostheses by elbow disarticu- lower limb. Prosthet Orthot Int 1987; I 982;63:89-91.
i lation and transhw11eral amputees. In ll :17-20. 11. Fishman S, Berger N, Edelstein J: ISNY
view of the historically low wearing 5. Ilizarov GA: The possibilities offered flexible sockets for upper-limb ampu-
y rates at this level, the rehabilitation by our method for lengthening va ri- tees. J Assoc Child Prosthet Orthot Clin
j
process must be o pt imized for ampu- ous segments in upper and lower 1989;24:8.
).
tees. Careful surgical intervention can limbs. Basic Life Sci l 988;48:323-324. 12. Daly W: Clinical app lication of roll-on
preserve useful length and enhance 6. Andrew JT: Elbow disarticuJation and sleeves for myoelectrically controlled
the amp utee's functional capabilities. transhumeral amputations: Prosthetic transradial and transhumeral prosthe-
I- In additio n , providing a well-fitted principles, in Bowker JH, Michael JW ses. J Prosthet Orthot 2000;12:88-91.
L (eds): Atlas of Limb Prosthetics: Surgi-
prosthesis with appropriate compo- 13. Salam Y: The use of silicone suspen-
31 ,a~ Prosthetic, and Rehabilitation Prin-
nents, traiJ1ing, and ongoing fo llow sion sleeves with myoelectric fittings.
ciples, ed 2. Rosemont, IL, American
up will improve prosthetic use and J Prosthet Orthot 1994;6:119-120.
te Academy of Orthopaedic Surgeons,
quality of function. As the patient's 2002, pp 255-264. (Originally pub- 14. Ross J, Radocy B: Preliminary experi-
tg needs and abilities change over time, ences in applying silicone suction
the prosthesis must likewise evolve if socket (35) prostheses to upper-
7. de Luccia N, Marin o HL: Fitting of
:h it is to continue to provide optimal electronic elbow on an elbow disartic- extremity amputees. J Assoc Child
r- Prosthet Orthot Clin 1990;25:27.
function. ulated patient by means of a new sur-
r- gical technique. Prosthet Orthot Int 15. Malone JM, Fleming LL, Roberson J, et
td 2000;24:247-251. al: Immediate, early, and late postsur-
a- References 8. Barcome DF, Eickman L: Prosthetic gical management of upper-limb an1-
jc putation. J Re/Jabil Res Dev
I. Pinzur MS, Angelats J, Light TR, management of high bilateral upper-
1g lzuierdo R, Pluth T: Functional Olllt- limb amputees: A case report. Orthot 1984;21 :33-41.
,le come following traumatic upper limb Prosthet 1980;34:3.
ed
n-
ta-
.ny
les
id-
:ap
'ers
)Il·
:ies
:sis
ific
ion
!tiC
md
fety
1im
,ing

Amputations About the Shoulder:
Surgical Management
Introduction
Fortllllately, amputations about the tions at the ultrashort transhumeral extensive reconstruction must be bal-
shoulder are rare, accou11ting for only level to be modified shoulder disartic- anced carefully. 9•10
a small percentage of all amputa- ulations because both the surgical There are also internal amputa-
tions. 1•2 Because surgeons may have closure and rehabilitation goals more tions, or en bloc resections, that re-
little practical experience with the va- closely match this level. Retaining the tain some distal limb function, such
riety of shoulder-level amputations, it proximal portion of the humerus pre- as the claviculectomy, scapulectomy,
becomes imperative for surgeons who serves a more normal shoulder con- and the intercalary shoulder resec-
may have to perform these procedures tour, allowing shirts and coats to tion, as described by Tikhor 11 and
to understand the complex anatomy drape more naturally. Depending on Linberg. 12 Typically, these procedures
and reconstructive goals of these dif- the reason for the amputation, a true are performed for osteomyelitis or
ficult amputations. Shoulder-level shoulder disarticulation can occa- primary bone tumors. Preserving the
amputations are most commonly sionally be performed with reason - neural and vascular supply to the dis-
considered for tumors, trauma, infec- able reshaping of the shoulder con- tal limb is essential to retain near-
tion, a11d congenital abnormalities. tour using the deltoid and pectoralis normal function of the hand, wrist,
For patients with congenital limb de- major for muscle reconstruction. Oc- and elbow. Regrettably, without the
ficiencies in the shoulder region, the casionally, no healthy soft tissue or important positioning function of the
need for surgical revision is rare and muscle for plastic reconstruction of shoulder girdle, the patient loses the
usually best avoided. this area is available. ability to use the hand in its normally
Although the techniques descdbed The scapulothoracic amputation, large sphere of activity, limiting func-
in this chapter are based on generally formerly referred to as the "forequar- tion to a much smaller zone of activ-
accepted principles and anatomic apter amputation," removes the upper ity in front of the body, as if the up-
proaches,3 there ru·e many occasions limb between the scapula and ilio- per limb were bound to the chest
when tissues required for standard racic wall, including the lateral clavi- wall. Because of the loss of stability
runputation techniques are simply not cle. Unfortunately, this amputation is and strength at the shoulder girdle,
available for reconstruction and clo- quite disfiguring because the lateral these procedures greatly compromise
sure of a shoulder amputation site.4- 8 neck structures slope directly onto the general strength of the upper limb, al-
This is especially true for cases involv- rib cage. Local soft tissue for recon- though grip strength can be retained.
ing malignant tumors, severe trauma, struction of a more normal shoulder Postoperative management for all
or necrotizing fasciitis, for which the contour is not available because the the various shoulder-level amputa-
smgeon will almost always need to i11- loss of ilie shoulder musculature typ- tions typically consists of careful re-
dividualize the surgical approach and ically necessitates this level of ampu- constructive closure, suction drainage
reconstrnctive plan based on which tation. Free-tissue transfer for later to help manage the dead space, and a
tissues are involved and which are sal- reconstruction of both the scapu- soft dressing witl1 compressive elastic
vageable. Considerable surgical inge- lothoracic amputation and shoulder wrapping around the thorax. Rigid
nuity can be required. disarticulation has been described dressings are often uncomfortable
Amputations at the shoulder in- and is technically possible, but almost and unnecessarily cumbersome in the
volve a variety of levels and tech- always as a later, staged procedure. shoulder area and do not provide the
niques. It is best to consider amputa- The risks, benefits, and timing of this same benefits for wound management
American Academy of Orthopaedic Surgeons 25 1

lat
Coracobrachialis muscle Biceps tendon,
long head Biceps muscle,
sic
short head an
tOJ
Coracobrachialis
muscle fill
Pectoralis tee
major muscle
ab
th
co
th,
Deltoid
muscle
m,
Lati ssimus
ne
A B c dorsi muscle
Triceps muscle, ere
Deltoid long head
muscle, hu
beveled m,
ne
Figure 1 Modified shoulder disarti culation (ul-
th
trashort t ranshumeral amputation) A, Skin inci-
Triceps fla
sion. B, Exposure and section of anterior mus-
muscle,
long head cles. C, Bone level and completed muscle ba
section. D, Closure of muscles. E, Completed am-
of
put ation. (Reproduced with permission from
Tooms RE: Amputations of the upper extremity, co
Coracobrachialis muscle in Canale ST (ed): Campbell's Operative Ortho- pc
D E paedics, ed 7. St. Louis, M O, Mosby-Year Book, de
1987.) th
WI
SU
and pain control. Nevertheless, early tric signals from the anterior, medial, h umeral attachment. Because the hu-
and posterior portions of the deltoid merus is transected just above the in - de
postoperative prosthetic techniques
are available and have been described muscle. This offers three independent sertion of the pectoralis major mus-
Tr
and used successfully by Burkhalter and proportional control signals to cle, this insertion is dissected off the
D
and associates 13 and Malone and as- actuate the prosthesis. When body- humeral shaft for later reattachment
sociates. 14 powered components are used, the to the residual humeraJ head. The A~
added bony width from the humeral latissimus dorsi muscle is also de- sc:
remnant is an advan tage because it tached from the humerus and tagged tr1
Amputation Levels increases the available excursion. for later reattachment. The subscapu- or
and Techniques The typical flap coverage is based laris tendon and the rest of the rota- fl.a
on the deltoid myofasciocutaneous tor cuff are left uudisturbed and at- th
Modified Shoulder
flap, which is advanced distally over tached to the humeral head. sic
Disarticulation
the axillary area (Figure 1). The iuci- The brach ia} vessels are identified, ric
The ul trashort transhumeral amputa- sions follow the anterior and poste- divided, and doubly ligated with care ce
tion can be considered a modified rior borders of the deltoid muscle, ex- to avoid ligation of the brachia! Tl
shoulder disarticuJation because there cept that the flap is not tapered plexus nerves with the vessels. The sh
is no intent to create a residual limb. distally. The distal portion of the inci- i1erves are separate~ and individually pr
A small portion of the proximal hu- sion should remove all or most of the transected under gentle traction, w
merus is retained to improve the con- axillary skin that is prone to sweating which allows retraction away from fo
tour of the shoulder region and assist and hair growth. Wheu the deltoid vessel ends and away from exposed o,r
in the fitting of shirts and other flap is not avaiJable for coverage, then areas that can be locations of pressure cl,
clothing. Equally important, even a anterior, posterior, or axillary skin or scarring. With an oscillating saw, te
small humeral remnant can allow the may be requ ired for closu re. The in- the hlm1erus is cut tl1rough th e surgi- jo
prosthetist to use voluntary motion to terval between the anterior deltoid cal neck. T he remaining proximal hu- PI
actuate an externally powered gripper and the pectoralis major muscles pro- merus will go into unopposed abduc- th
via miniature touch pads or similar vides a direct approach to the hu- tion because of tl1e unopposed action tic
microswitches. vVhen the deltoid merus and the shoulder region. Fol- of the rotator cuff. The edges of the m
muscle is carefully reattached, some lowing ligature of the cephalic vein, bone should be gently row1ded to re- m
amputees can differentiate myoelec- the deltoid is gently elevated from its move sharp edges, especially on the jo

Chapter 20: Amputations About the Shoulder: Surgical Management 253
lateral and anterior surfaces. The re-

Musculocutaneous nerve Pectoralis
sidual humerus sho uld then be bal-
ephalic minor
anced with reattachment of the pec- vein muscle
toralis major and the latissimus dorsi
muscles. If muscle rebalancing is not
teclrn ically possible, then excessive
abduction can occur over time, and Pectoralis
this complicates prosthetic fitting and major
Where deltoid muscle
cosmesis. Baumgartner 15 suggests is sectioned
that, for slightly longer humeral seg-
ments, a primary arthlfOdesis in a
neutrnl position should be consid-
A B
ered. Because the small portion of Biceps muscle,
humerus does help retain a more nor- short head
mal shoulder contoux, there is no
need for osteotomy or reshaping of Infraspinatus
muscle
the acromion or coracoid process. latissimus
I- Teres minor
The deltoid myofasciocutaneous dorsi muscle
i- muscle
;- flap is advanced distally over the re- Axillary nerve Teres major ~Triceps
e balanced humeral head, with the bulk muscle muscle,
1· of this muscle providing the final long head
11 Triceps
contour of the shoulder and axillary Triceps muscle,'
1>'
y. muscle,
)·
portion of the incision. Typically, lateral head lateral head
k, deep suction drainage is placed under c D
the deltoid muscle. T he flap is inset
witl1 a deep fascial closure, and the
]·
subcutaneous tissue and skin are
closed with gentle techniques.
1·
s- True Shoulder
1e
Disarticulation
11t
1e As with the modified procedtue de-
e- scribed above, the ideal coverage for a
!d true shoulder disarticulation is based
on the deltoid myofasciocutaneous
E F
Ll·
a- flap, which is advanced distally over
the axillary area (Figure 2). The inci- Figure 2 True shoulder disarticulation. A, Skin incision. B, Exposure and section of the
lt·
neurovascular bundle. C, The deltoid muscle is reflected; the arm is placed in internal ro-
sions follow the anterior and poste- tation, and the supraspinatus, infraspinatus, and teres minor tendons and the posterior
:d, rior borders of the deltoid muscle, ex- capsule are sectioned; t he coracobrachialis and biceps muscles are sectioned at the cora-
t.re cept the flap is not tapered distally. coid. D, The arm is placed in external rotation, and the subscapularis muscle and ante-
The distal portion of the incision rior capsule are sectioned. E, Th e muscles in the glenoid fossa are sutured. F, Completed
ial
amputation. (Reproduced with permission from Tooms RE: Amputations of the upper
he should remove the axillaq skin that is
extremity, in Canale ST (ed): Campbell's Operative Orthopaedics, ed 7. St. Louis, MO,
lly prone to sweating and hair growth. Mosby- Year Book, 1987.)
>D, When the deltoid flap is not available
,m for coverage, the anterior, posterior,
ed or axillary skin may be required for humerus for use in closure and cover- chial vessels are identified, divided,
closu re. The interval between the anage of the glenoid axea. The latissimus and doubly ligated. As with the modi-
lW, terior deltoid and. the pectoralis ma- dorsi muscle is also removed from the fied shoulder disarticulation, care is
gi- jor muscles provides a direct ap- humerus for later reattachment into taken to avoid entrapment of the bra-
lt!· proach to the proximal humerus and the glenoid fossa. chial plexus nerves with tlle vessels.
lC· the shoulder region. Following liga- In the true shoulder disaxticula- If adequate muscle tissue remains,
on tion of the cephalic vein, the deltoid tion, following detachment of the ro- tliere is no need to do any contouring
the m uscle is gently elevated off of its hu- tator cuff, the capsule is divided first or reshaping of the glenoid fossa, the
re- meral attachment. The pectoralis ma- superiorly and anteriorly, then inferi- acromion, or the coracoid process.
the jor insertion is then dissected off the orly, and finally posteriorly. The bra- The pectoralis major and the latissi-

coverage. 17· ' 8•28•29 Malignant tumors 3 Cl

often invade regional lymph nodes as neo
well as the chest wall, a situation that diss
can complicate the extent of the Jar
operation.30- 32 Not infrequently, pri- Joe,
mary closure is impossible. Achieving at I
wound closure may require a staged clei
procedure with initial open wound pro
management and later coverage with Th(
skin or composite grafts. Several re- be
cent articles, including those by Cord- mi<
eiro and associates9 and Zachary and sels
associates, 10 highlight the use of free- pro
tissue transfer in which tissue is occa- ma
Figure 3 A, Appearance fol lowing scapulothoracic amputation. B, Clothing drapes in an
sionally obtained from the distal as- tor,
awkward fashion. C, A simple shoulder cap can improve the contour of the chest and
shoulder area. (Courtesy of Prosthetics Resea,rch Study, Seattle, WA.) pect of the amputated limb to obtain ces:
closure following radial tumor resec- su1:
tions. div
mus dorsi muscles can be sutured to primary indications are malignant tu- cos
remnants of capsule and to the rota- mors, severe proximal necrotizing fas- Anterior Approach tW(
tor cuff tendons to fill the glenoid ciitis, or severe trauma. 16- 18 With ne- In most situations in which a scapu- sul
fossa. The attachment of the muscle crotizing fasciitis in the shoulder lothoracic amputation is required, the pe1
to the capsule or the edge of the gle- girdle, patients are typically near deltoid muscle and overlying tissues the
noid fossa is important to avoid a death, and the procedure becomes are absent, infected, or involved with vei
mobi.le muscle sling that can slide emergent, as the last hope to save the the malignancy and, therefore, are not se:i:
back and forth over the glenoid, cre- patient's life. The amputation is unfor- available for reconstruction. In the lig.
ating a bursal area and a potential tunately quite disfiguring because the standard anterior approach, a fascio- ne1
source of grinding and pain. The del- lateral neck structures slope directly cutaneous flap is created from the su- pie
toid myofasciocutaneous tlap is ad- onto the rib cage, resulting in a signif- perior aspect of the shoulder and ve~
vanced distally for coverage and final icant cosmetic deformity (Figure 3) . neck with an incision that starts near tra
contouring of the shoulder and axil- The su1·gery is extensive but not es- the medial clavicle and passes laterally
lary portion of the incision. Suction pecially complicated when performed along the anterior-inferior aspect of m1
drainage is typically placed deep to using standard techniques tl1at have the clavicle as far latera.lly as the mor- orl
the deltoid muscle. As noted previ- been developed over the last bid tissue safely permits.33 The inci- ini
ously, if the deltoid muscle insertion century. 19 - 27 There are two main ap- sion then proceeds up and over the La
is sufficiently stabil ized, the amputee proaches to the scapu.lothoracic am- shoulder near the acromion to the ac1
may have three independent myoelec- putation, depending on whether the spine of the scapula and then toward ca:
tric control sites. subclavian vessels are approached and the posterior midline, dropping infe- to
If the deltoid muscle is not avail- managed from the anterior or the pos- riorly to the spine of the scapula and an
able to pad the shoulder region, re- terior side. The anterior approach then distally along the medial border SC.
ducing the prominence of the ante- starts by preliminary exposure and os- of the scapula. Elevating this fasciocu- to:
rior acromion and coracoid process teotomy of the clavicle to visualize the taneous flap exposes the clavicle and m:
should be considered. Most com- vessels. The posterior approach begins superior scapular area. The inferior di
monly, the anterior third of the acro- with detachment of the muscles from portion of the incision starts near the ill
mion is removed and smoothed and the medial and superior scapula, a l- middle of the clavicle, then proceeds lir
the coracoid process shortened to lowing mobilization of the arm and toward the coracoid process, along
minimize abrupt changes in bony scapula latera.lly to a.llow the vessels to tl1e deltopectoral groove to the ante- m
contour under the fasciocutaneous be visualized from u11derneatl1 the rior axillary fold, across the axilla to lll
closure. scapula. Several reports indicate that the posterior axillary fold, and finally th
blood loss may be less with the poste- traverses the scapula to join the supe- to
Sea pu lothoracic rior approach, but no direct compara- rior incision near the distal angle of m
Amputation tive studies have been published. the scapu lar body (Figure 4). o,
This radical procedw·e surgically re- Because tissue involvement with The clavicle is exposed and divided fL
moves the entire upper limb, includ- neoplasm or infection can be exten- near the lateral margin of the sterno- fo
ing the scapula and most of the clavi- sive, careful planning is required to cleidomastoid muscle. If not involved <L
cle off of the thoracic wall. The obtain adequate skin and soft-tissue with diseased tissue, the medial 2 to cl

Chapter 20: Amputations About the Shoulder: Surgjcal Management 255
3 cm of clavicle can be left intact. If

necessary, it can be removed by careful
dissection through the sternoclavicu- Posterior
Jar joint. The external jugular vein is
located just above the medial clavicle
at the lateral border of the sterno-
cleidomastoid muscle and should be
i protected and preserved if possible.
1 The lateral portion of the clavicle can
be mobilized or removed at the acro-
mion to visualize the subclavian ves- A
:l sels. Exposure of the vessels is im- Trapezius muscle
proved by releasing the pectoralis
major from the humerus and the pec-
toralis minor from the coracoid pro-
Clavicle Subclavian
n cess. More proximal exposure of the vein
subclavian vessels is obtained by fixst Subclavius
muscle
dividing the axillaxy fascia, then the
Pectoralis major
costocoracoid membrane that lies be- muscle
tween the pectoralis minor and the Pectoralls minor
L- subclavius, and finally elevating the c muscle
D
ie periosteum from the deep surface of
:s the clavicle. The subclavian artery and
h vein are identified and carefully ligated
)t separately. Care must be taken to avoid
Le ligating any of the brachia) plexus
)- nerves with the vessels. The brach ial
1- plexus is dissected from around the
1d vessels, and each trunk is separately
H transected and allowed to retract.
ly
:>f
Sectioning the latissimus dorsi
muscle allows the arm to fall posteri-
lnfrasplnatus
muscle
Teres major muscle
(
r- orly away from the chest wall, improv-
:i- ing access for the deep dissection. F
1e Later, by positioning the arm forward
1e across the chest, the posterior incision
rd can be carried along the scapular spine Figure 4 Scapulothoracic amputation t hrough an anterior approach. A, Skin incision.
B, Resection of the clavicle. C, Lifting of the pectoralis major muscle. D, Section of the
e- to release the insertion of the trapezi us
vessels and nerves after incision t hrough the axillary fascia and insertion of the pectora-
1d and along the medial border of the l is minor, the costocoracoid membrane, and the subclavius. E, Section of supporting
er scapula to release the omohyoid, leva- muscles of the scapula. F, Completed amputation. (Reproduced with permission from
u- tor scapulae, rhomboideus major and Tooms RE: Amputations of the upper extremity, in Canale ST (ed): Campbell's Operative
1d minor, and the serratus anterior mus- Orthopaedics, ed 7. St. Louis, MO, Mosby-Year Book, 1987.)
or cles. The final soft-tissue attachments
he in the axillary area are divided, and the referred to as "posterior" and "ante-
portive dressings are applied with gen-
ds limb is removed. rior," in actuality they might be best
tle pressure, achieved by secure wrap-
ng Reconstruction with the remaining
ping axound the chest wall. described as "superior/posterior" and
:e- muscles occurs after removal of the
"inferior/anterior." The patient is po-
to underlying morbid tissue. Typically, Posterior Approach sitioned on the uninvolved side near
lly the pectoralis major muscle is sutured
to the trapezius muscle, and the re- In 1922, Littlewood34 described a tech- the edge of the operating table. Two
maining muscles are closed in layers nique for scapulothoracic amputation incisions are required-one posterior
over tbe lateral chest wall. The skin approaching the shouJder area initially (cervicoscapular) and one anterior
ed flaps are brought together and tailored from the posterior aspect (Figure 5). (pectoroaxillary). Later, the anterior
10- for accurate approximation. Suction Some consider this approach to be incision passes through the axillary
ed drainage is placed, and the wound is technically easier than the anterior ap- area to join the posterior incision and
to closed with interrupted sutures. Sup- proach.5·35 Although the incisions are allow removal of the limb. The poste-

gion, the branches of the transverse trol. 30, 36 Preserving the neural and sh<
cervical and transverse scapular arter- vascular supply to the distal lin1b is aft
ies, are .identified and ligated. The soft essential to retain near-normal func- Tei
tissues are then freed from the clavicle, tion of the hand, wrist, and elbow. Re- an
and the bone is divided at its medial grettably, without the important posi- ea<
end. The subclavius muscle is also ditioning function of the shoulder po
vided. girdle, the placement of the hand in fe,
The limb is then mobilized anteri- its normally large sphere of activity is on
orly and laterally so that the surgical lost, limiting its function to a much in!
approach can continue beneath the smaller zone of activity in front of the
scapula. As the limb is mobilized later- body, as if the upper limb were bound
Sc
ally, the subclavian vessels and the bra- to the chest wall. Although grip
chia! plexus are placed under tension, strength can be retained, overall up- Sc
per limb strength is greatly compro- is<
making their identification easier. The
mised in these procedares because of co:
subclavian artery and vein are identi-
the lack of stability and strength at th1
fied, separated, and carefully doubly
the shoulder girdle. 37 wa
ligated. Care must be taken to avoid li-
Sy
gating any of the brachia] plexus
Figure 5 Scapulothoracic amputation
nerves with the vessels. The brachia!
Claviculectomy ve:
through a posterior approach (the Little-
Resection of all or some of the clavi- ulc
wood technique). A, Skin incision. B, Ex- plexus is identified from around the
cle, although rarely indicated, has oc- op
posure of the vessels after exposure of vessels, and each trunk is separated,
the muscles holding the scapula to the casionally been recommended to treat is
transected, and allowed to retract.
chest wall and section along the scapular localized malignancy or chronic pr
The anterior incision is then begun gu
border. (Reproduced with permission
at the middle of the clavicle. It curves osteomyelitis. 38- 42 The amount of re-
from Tooms RE: Amputations of the up-
section is determined by the nature, ne
per extremity, in Canale ST (ed): Camp- inferiorly just lateral, but parallel, to of
bell's Operative Orthopaedics, ed 7. St. the deltopectoral groove, extends extent, and location of the disease.
Louis, MO, Mosby-Year Book, 1987.) across the anterior axillary fold, and is The surgical approach is along the an-
terior aspect of the clavicle and typi- fo
finally carried inferiorly and posteri- pc
orly to join the posterior a.xillaq inci- cally extends the length of the bone,
from the sternoclavicular joint to the de
rior incision is made first. Beginning sion at the lower third of the axillary ac
acromioclavicular joint. Biopsy sites,
at the medial end of the clavicle, the border of the scapula. The pectoralis an
if present, are widely excised.
incision extends laterally just superior major and minor muscles are divided, rn,
The deltoid muscle insertion is ele-
to the clavicle along the entire length completing removal of the limb. ca
vated first to expose the distal clavicle.
of the bone. The incision proceeds up Muscle closure is done in layers with tit
The conoid and trapezoid ligaments
over the acromion process to the pos- retained muscles as allowed by the pa- Ty
and the capsule of tl1e acromioclavic-
terior axillary fold and then continues thology. The skin flaps are trimmed ti(
ular joint are divided. Moving toward
along the axillary border of the scap- to fit and closed with interrupted su- di
the midline, the sternocleidomastoid
ula to a point inferior to the distal tures. Typically, suction drainage in m
muscle is carefully sectioned, protect-
scapular angle. Finally, the posterior conjunction with a firm pressure ing the external jugular vein. Medi- th
incision curves medially to end dressing to the chest wall are used to be
ally, a portion of the pectoral is major
2 inches from the midline of the back. facilitate wound management. ci;
must be incised. The subclavicular
A large full-thickness flap of skin, sub- muscle is excised in cases of tumor as ta
cutaneous tissue, and fascia (if not dis- Internal Amputations, or llf
the clavicle is lifted from its bed, but
eased) is elevated medially off the En Bloc Resections
the muscle is often retained in pa-
scapular muscles to a point just medial Internal amputations, or en bloc re- tients with osteomyelitis. In some ta
to the vertebral border of the scapula. sections, are performed in an attempt cases, the medial clavicle can be rein
Next, the muscles holding the scap- to retain some distal limb function. tained, and in others, the medial ster- ar
ula to the chest wall are divided along These procedmes include claviculec- noclavicular capsule, sternohyoid th
the scapular border. The trapezius, tomy, scapulectomy, and intercalary muscle insertion, and costoclavicular re
latissimus dorsi, levator scapulae, shoulder resection, as described by ligament are divided to allow removal ar
rhomboideus major and minor, serra- Tikhor 11 and Linberg. 12 Typically, of the entire clavicle. ta
tus anterior, and omohyoid muscles these procedures are performed for r}
Closure is performed in layers to
are all identified and divided parallel primary bone tumors and commonly minimize dead space. Suction drain- 111
with the scapula. The main vessels that used adjuvant radiation or chemo- age is placed, and compression dress- ti,
supply this part of the shoulder re- therapy to improve local twnor con- ings and a sling are applied. The SJ

nd shoulder and the arm are mobilized wud and outward to allow access to tures for limited elbow, wrist, and
is after initial wound healing has begun. the subscapular space. The superior hand function, was first advanced by
lC- Technical variations, based on the site trapezius is divided from t he scapular Tikhor 11 and Linberg. 12 The surgical
le- and nature of the disease, requ ire that spine, the acrom ion, and th e distal goal is to suspend the remaining hu-
,si- each surgery be individualized. Re- clavicle, followed by sectio ning of the merus to the remaining clavicle or
:ler ported series usually include only a levator scapulae muscle. The superfi- chest wall to minimize excessive
m few patients, and there are few data cial cervical and descending scapular drooping. 5o-54 Many individuals use
y is on the fw1ctional linutations follow- vessels are isolated and Ligated. The an orthotic device to strap or stabilize
1ch ing clavicular resection.39-43 suprascapular vessels and nerves are the upper arm to the chest wall to
the exposed, and as the scapula is lifted take advantage of the retained elbow,
md further laterally from the thorax, the wrist, a nd hand function . Although
Scapulectomy
;rip brachia! plexus and axillary vessels the sphere of hand function is limited
Scapulectomy is used primarily for come into view. to activities near the midline of the
up-
isolated neoplasms of the scapula, a The supraspinatus, infraspinatus, body, many patients appreciate hav-
1ro-
condition only rarely seen. Excision of and serratus anterior muscles are re- ing a sensate, functioning hand to as-
! of
the scapula for primary bone tumors moved along with the scapula. Th e sist in performing the activities of
t at
was first described in 1864, by James nature and extent of the pathologic daily living. In a review of 19 patients
Syme, professor of surgery at the Uni- process will dictate whether it is pos- with an average follow- up of more
versity of Edinburgh.44 When scap- sible to preserve the acromion and the than 6 years, Voggenreiter and associ-
ulectomy is performed following a bi- con tinuity of the superior trapezius- ates55 concluded that despite a 74%
av1-
opsy, wide resection of the biopsy site deltoid suspensory system. The del- complication rate, the Tikhoff-
oc-
is required. The surgical description toid muscle is freed from the spine of Linberg procedure had a functional
reat
presented here can serve as a gen eral the scapula and the acromion. The outcome superior to scapulothoracic
)Die
guideli11e, but variations are often teres major and the Jong head of the amputation.
: re-
needed, as determined by the extent triceps muscles are transected. The For tbjs procedure, patients are
:ure,
of the disease. 45"49 subscapular artery is visualized and li- positioned in a full lateral position,
:ase.
· an-
This surgery is most often per- gated as it comes off the axillary ar- lying o n the tminvolved side. The
formed with the patient prone, a s up- tery. The tmderlying axillary and ra- arm, shoulder, and shoulder girdle are
ypi-
port placed under the affected shoul- dial n erves are preserved. draped free for manipulation and po-
one,
der, and the arm draped to allow Disru·ticulation of the acromioclav- sitioning during surgery. The incision
I the
;ites, access to the entrre scapular region icular joint and detachment of the cor- resembles a tennis racq uet with the
and free movement of both the hu- acoclavicular ligaments allow further "handle" starting along the clavicle
; ele- merus and scapula. The procedure mobilization of the scapula. Finally, and extending laterally out toward the
ricle. can also be perfo rmed with the pa- the pectoralis minor, coracobrachia- arm. The racquet-shaped portion of
1ents tient in a lateral position if necessary. lis, and the short head of the biceps the i11eision extends distally along the
avic- Typically, th e incision begins at the muscles are detached from the cora- deltopectoral groove to the midpoin t
ward tip of the acromion and extends me- coid process, and the rotator cuff is of the medial edge of the b iceps,
stoid d ially along the scapular spine to its transected during external and inter- curves laterally across the deltoid in-
,tect- midportion, then curves distally to nal rotation of the humerus, com- sertion, and then proceeds posteriorly
iledi- the inferior angle of the scapular pletely freeing the scapula. A portion onto the back toward the inferior an-
riajor body. Muscles both deep and superfi- of the residual rotator cuff insertion gle of the scapula. Finally, the incision
cular cial to the scapula are resected, as dic- can be used to stabilize the clavicle, curves upward to join the original
or as tated by the type and e:xtent of the suspend the humerus, and preserve a clavicular incision near the acromio-
l, but neoplasm. more normal shoulder contour. The clavicular joint.
1 pa- The latissimus dorsi muscle is de- wound is closed in layers over a suc- Deeper dissection is performed
some tached from the inferior a11gle, allow- tion drain. Compression dressings are from both the anterior and posterior
,e re- ing the scapula to be tilted upward applied, and the arm is supported in a aspects and, in a sense, combines the
. ster- and outward. T he vertebral border of Velpeau's bandage. classic an terior technique of scapu-
hyoid the scapula is dissected free, and the lothoracic amputation with the poste-
icular remaining insertions . of the inferior Internal or lntercalary rior approach. The brachial plexus
n oval and middle trapezius muscles aTe de- Shoulder Resection and major vessels are preserved. After
tached from the scapular spine. Th e (Tikhoff-Linberg Procedure) the scapulothoracic muscles are de-
~rs to rhomboids are exposed beneath this The technique of removing most of tached and the deltoid, biceps, and
irain- interval and then divided. The d issec- the muscles and bones of the shoul- triceps muscles aTe sectioned, the hu-
dress- tion continues along the subscapular der region, while p reserving the nec- merus is transected at or below the
. T he space. The scapula is mobilized up- essary neurologic and vascular struc- surgical neck, as determined by the

extent of d isease. The proximal lrn- brachia! plexus injury leaves patients beneficial as an adjunct to the trans-
merus, scapula, and most of the clavi- with no motor or sensory function, humeral amputation. This is particu-
cle are resected en bloc. The biceps, they need to be advised about the ad- larly true if prostl1etic fitting is to be
triceps, and deltoid muscles are at- vantages and disadvantages of retain- attempted because the patient can
tached to the thoracic wall, while the ing a nonfunctional arm. Patients generate significant range of motion
trapezius suspends the arm as firm ly need time to come to terms with the as well as stabilize the prosthesis using
as possible without compromising hope versus the practical reality of the scapular muscles (Figure 6) . If
neurovascular integrity. The tissues neurologic recovery. Education, sup- both joints are flail, arthrodesis is
are closed to minimize dead space, port, and visitor programs with other probably not beneficial, and pros-
and suction drninage is placed. Soft brachia! plexus injury patients tend to thetic fitting will be more difficult
compression dressings and a Velpeau's be most helpful. This process simply and require a more extensive socket to
bandage are used postoperatively. cannot be rushed. stabilize the prosthesis by encompass-
The arm requires support with a Amputation is considered most of- ing more of the chest and back. Con-
sling or an orthosis for at least several ten to unload the nonfunctional versely, if both joints have motor con-
months during the healing process, weight of the paralyzed upper limb trol, arthrodesis is not needed. A
and many patients require long-term from tl1e shoulder and scapulotho- Prosthetic expectations in these
stabilization of the upper arm to the racic joints and to remove a part that patients should be very conservative.
chest wall to maximize distal function hinders function because it simply gets Prosthetic fitting adds weight to a
by overcoming the absent shoulder in t he way. Discussing the specific dysfunctional shoulder girdle, often
stability. Rehabilitation training con- goals for function, cosmesis, and pros- defeating one of the original goals of
centrates oh strengthening the mus- thetic use before the surgery can be the amputation by stressing the neck
cles of the neck and trunk and of the very helpful for both the patient and and shoulder region. More recent de-
arm distal to the site of amputation of the surgeon. The most common am- signs that stabilize the prosthesis on
the humerus. With this approach, no putation plan is for either a trans- the torso are often preferable to ear-
attempt is made to restore a sem- humeral amputation or a shoulder lier approaches that primarily load
blance ·of shoulder function, but an disarticulation to manage a totally the humeral remnant. Although most
adequate degree of hand, wrist, fore- dysfunctional arm after a complete
patients who decide to proceed with
arm, and elbow function can be brachia! plexus avulsion. Some pa- amputation hope that the prosthesis
achieved. The defect in the shoulder tients use part of the flail arm to sta-
will restore their function, most ulti-
bilize objects, especially when working
girdle and shoulder contom can be mately choose to not wear an active
at a desk. In these cases, a midlength
concealed with a light shoulder pad- prosthesis or use it in a limited way
transhumeral amputation retains
ding to provide a more normal con- for very specific tasks. Surgeons con-
enough of the arm to serve that role,
tour of the shoulder area under cloth- sulted for assistance in the decision- D
but it removes enough to improve the
ing. making process need to understand
problem of"dead" weight and some of
the underlying dream and also the
Amputation for Severe the cmnbersomeness of a flail arm.
eventual realities. Occasionally, a very
This level of amputation also retains inj1
Brachia! Plexus Injury lightweight, cosmetic prosthesis is de-
enough upper arm to accommodate she
Modern management of severe bra- attempts at prosthetic fitting. Other sired and indicated to help restore
thr
chia! plexus injuries is directed much patients find that the remaining flail body image. Some patients who ini-
tially use an active prosthesis ulti- for
more aggressively at repairing and upper arm remains a significant hin- ter
grafting the damaged nerve segments drance and prefer a shoulder disartic- mately conclude that a biomechani-
de.
than in the past. The tremendous ulation. cally simpler passive artificial arm is
ar,e
number of different injury patterns, If a transhwneral amputation is
sufficient for theiJ needs.
of
the unpredictable nature of recovery, planned, a concomitant or secondary in~
and the complex emotional issues shoulder arthrodesis can be consid- Postural wa
mandate that management decisions ered, but the decision remains contro- of
be indjvidualized. Although amputa- versial and should be individualized.
Abnormalities te11
tion of all or part of the dysfunctional One clinical series reported a slightly Following an,
limb can be considered when recon- better rate of return to work in a Shoulder-Level inE
structive efforts have failed, I believe group of patients with transhumeral alt
it is not appropriate to encourage am- amputation without shoulder arthro-
Amputation lin
putation at an early stage. Patients desis.56 In my opinion, if there is no The normal symmetry and balance to
need time to adapt to the injury, allow glenohu.n1eral joint motor control, around the shoulders and upper body plf
for recovery, and learn about recon- but there is active scapulothoracic is altered following high-level upper Co
structive options. Even if a complete motion, shoulder arthrodesis can be limb amputation or brachia! plexus aft

Ch apter 20: Amputations About the Sh oulder: Surgical Managem ent 259
t
:>
A B
e
a
n
>f
k
Figure 6 A patient w it h a brachia! plexus
n injury required amputati on after a severe
r- burn injury to th e asensate hand. At·
.d tempted abduction (A) and forwa rd flex-
ion (B) before glenoh1clmeral arthrodesis
st
resu lts in scapulothoracic motion only be-
:h cause of a f lail glenohumeral joint. After
is glenohumeral arthrodesis, t he patient
.l- can successfully abduct (C) and forward
te flex (D) to approximately 30°. E, Pros-
thetic fitting with traditional body-
:1y
powered device was successful with an
l-
extended socket t o better manage t he
11- D weight of the prosthesis. (Courtesy o f
1d John Bowker, MD, Miami, FL.)
1e
ry
injury. The normal posture and m inimizing this postural tendency. In
e-
shoulder pos1t1on is maintained most circumstances, the shoulder gir-
re
through a balance of the muscular dle elevation is inevitable, but it can
ii-
forces and the weigh t of the arm. Af- be minimized by appropriate physical
ti-
ter upper limb amputation, the m us- therapy.
u-
cles that elevate the shoulder girdle For some individuals with
is
are no longer balanced by the weight shoulder-level amputation, the spine
of the arm and the muscles depress- can assume a postural scoliosis during
ing the shoulder. The result is an up- standing (Figure 7). Muscle imbalance
ward elevation described as a hiking is again considered to be the primary
of the shoulder. This "high shou lder" cause, coupled with the change in de-
tends to accentuate the cosmetic loss pendent weight. Although it can be
and is very noticeable and disconcert- seen in adults, it is more often seen in
ing to many patients. Unfortunately, younger, skeletally immature ampu-
although wearing a full prosthetic tees. The combined postural deformi-
limb can be helpful by addi ng weight ties of high thoracic scoliosis and ele-
ice to the shoulder, it does not com- vation of the shoulder girdle produce
Figure 7 Posterior view of a man w ith
,dy pletely eliminate the high shoulder. asymmetry of the head and neck, with postural scoliosis and elevation of the
,er Corrective exercises begun very soon the head appearing to be placed asym- shoulder area following left shoulder dis-
ms after the amputation can be helpful in metrically as the person stands. articulation.

In general, no corrective splinting 13. Burkhalter WE, Mayfield G, Carmona 27. Zancolli E, Mitre HJ, Bick M, et al:
or orthotic device successfully cow1- LS: The upper-extremity amputee. In tersca p ulo-cleidothoracic disarticu-
teracts these postural changes associ- Early and immediate post-surgical lation: lnd ications and technique. 42. ~
ated with shoulder-level amputation. prosthetic fitting. J Bone Joint Surg Am Prensa Med Argent 1965;52:1122-1126. I
Neck and shou lder girdle exercises of- l 976;58:46-51. 28. Mansour KA, Powell RW: Modified
fer the most effective prophylaxis and 14. Malone JM, Fleming LL, Roberson J, et technique for radical transmediastinal 43. l
treatment. al: Immediate, early, and late postsur- forequa rter amputation and chest wall
gical management of upper-limb am- resection. J Thorac Cardiovasc Surg
References putation. J Rehabil Res Dev 1984;21: 1978;76:358-363.
1. Anderson-Ranberg F, Ebskov B: Major 33-41. 29. Trishkin VA, Saal<ian AM, Stoliarov Vl, 44.:
upper extremity amputation in Den- IS. Baumgartner R: Upper extremity am- Kochnev VA: lnterscapulothoracic I
mark. Acta Orthop Scand l 988;59:321- putations, in Surgical techniques in Or- amputation in treating malignant tu-
322. thopaedics and Traurnatology. Paris, mors of the upper extremity and 45.
2. Chappell PH: Arm amputation statis- France, Elsevier, 2001, p 14. shoulder girdle. Vestn Khir Im I Grek
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atory statistical analysis. Int JRehabil Elias EG: Evaluation of forequarter 30. Marcove RC: Neoplasms of the shoul- 46.
Res 1992;15:57-62. amputation in malignant diseases. der girdle. Orthop Clin North Am 1975;
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1975;6:553-564. malignant neoplasms of the extremi- amputations of the extremities in the 47.
4. Bauman PK: Resection of the upper ties: fnterscapulothoracic amputation, treatment of cancer. Surg Gynecol
extremity in the region of the shoulder hjp joint disarticulations and interilio- Obstet 1947;84:1105-1116.
joint. KlzirurgArkh Velyaminova 1914; abdominal amputation: A report of
32. Pack GT, McNeer G, Coley BL:
30:145-149. end results in 228 cases. J Bone Joint
Interscapulo-tboracic amputations for
5. Burgess EM: Sites of amputation elec- Surg Am 1956;38:249-262.
malignant tumors of the upper ex-
tion according to modern practice. 18. Roth JA, Sugarbaker PH, Baker AR: tremity: A report of thirty-one consec-
Clin Orthop 1964;37:17-22. Radical forequar ter amputation with utive cases. Surg Gynecol Obstet 1942;
6. Burton DS, Nagel DA: Surgical h·eat- chest wa ll resection. Ann Thorac Surg 74:161.
1984;37:432-437.
ment of malignant soft-tissue tumors 33. Tooms RE: Amputation surgery in the
of the extremities in the adult. Clin 19. Bogacki W, Spyt T: Interscapular-
upper extremity. Orthop Clin North
Orthop 1972;84:144-148. tboracic amputation of the arm. Am 1972;3:383-395.
7. Grimes OF, Bell HG: Shoulder girdle Nowotwory 1980;30:261-264.
34. Littlewood H: Amputations at the
amputation. Surg Gynecol Obstet 1950; 20. Haggart GE: The technique of inter-
shoulder and al the hip. BM]
91:201. scapulothoracic amp utation. Lahey
1922; l :381.
8. Jal! CB, Bechtol CO: Modern amputa- Clin Bull 1940;2: 16.
35. Knaggs RL: Mr. Littlewood's method
tion technjque in the upper extremity. 21. Ham SJ, Hoekstra HJ, Schraffordt KH,
of performing the interscapulo-
J BonejointSurgAm 1963;45:1717- et al: The interscapulothoracic ampu-
thoracic amputation (Letter to the
1722. tation in the treatment of malignant
editor). Lancet 1910;1:1298.
9. Cordeiro PG, Cohen S, Burt M, Bren- diseases of the upper extremity with a
review of the literature. Eur J Surg 36. Salzer M, Knahr K: Resection of ma-
nan MF: The total volar forearm mus- lignant bone tumors. Recent Results
culocutaneous free flap for recon- Oncol 1993;19:543-548.
Cancer Res 1976;54:239-256.
struction of extended forequarter 22. Hardin CA: lnterscapulothoracic am-
putations for sarcomas of the upper 37. Kneisl JS: Function after amputation,
amputations. Ann Plast Surg 1998;40:
388-396. extremity. Surgery 1961;49:355-358. artbrodesis, or arthroplasty for tumors
23. Levinthal DH, Grossman A: lnter-
about the shoulder. J South Orthop
10. Zachary LS, Gottlieb LJ, Simon M, et
scapulothoracic amputations for ma- Assoc 1995;4:228-236.
al: Forequarter amputation wound
coverage with an ipsilateral, lymphe- lignant tumors of the shoulder region. 38. Abbott LC, Lucas DB: The function of
dematous, circumferential forear m Surg Gynecol Obstet 1939;69:234. the clavicle: fts surgical significance.
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1993;9:103-107. 25. Nadler SH, Phelan JT: A technique of 40. Kochhar CL, Strivastava LK: Anatomi-
11. Tikhor PT: Tumor Studies. Russia, interscapulo-tl10racic amputation. cal and functional considerations in
1900. Surg Gynecol Obstet l 966;122:359-364. total claviculectomy. Clin Orthop 1976;
12. Linberg BE: lnterscapulothoracic re- 26. Sperling P, Rloding H: fnterthoraco- I 18:199.
section for malignant tumors of the scapular an1putation (forequarter am- 41. Lewis MM, BaUet FL, Kroll PG, Bloom
shoulder joint region. J Bone Joint Surg putation). Zentralbl Chir 1981;106: N: En bloc clavicular resection, opera-
1928;10:344-349. 340-343. tive procedure and postoperative test·

ing of function. Clin Orthop 1985;193: lignant bone and soft-tissue tumors. der (Tikhoff-Linberg). Ital J Ort'hop
214. J Surg Oncol 1999;72:130-135. Traumatol 1985;ll:l5l-l57.
42. Spar I: Total claviculectomy for patho- 48. Rodriguez JA, Craven JE, Heinrich S, 53. Janecki CJ, Nelson CL: En bloc resec-
5. logical fractures. Cli11 Orthop 1977; Wilson S, Levine EA: Current role of tion of the shoulder girdle: Technique
129:236-237. scapulectomy. Am Surg 1999;65: l 167- and indications. J Bone Joint Surg Am
al 43. McLaughlin J: Solitary myeloma of the 1170. 1972;54: 1754-1758.
111 clavicle with long smvival after total 54. Ye Q, Zhao H , Shen J: Modified en
49. Turnbull A, Blumencranz P, Fortner J:
excision: Report of a case./ Bone Joint bloc resection procedure for malig-
Scapulectomy for soft tissue sarcoma.
Surg Br 1973;55:357-358. nant tumor of the shoulder girdle.
Can J Surg 1981;24:37-38.
n, 44. Syme J: Excision of the Scapula. Edin- Acta Acaderniae Medicinae Sinicae
bmgh, Scotland, Edmonton and Dou- 50. Pack GT, Baldwin JC: The Tikhor- 1994; 16:378-382.
glas, 1864. Linberg resection of shoulder girdle.
55. Voggenreiter G, Assenmacher S,
45. DeNancrede CBG: End-results of total Surgery 1955;38:753-757.
Schmit-Neurburg KP: Tikhoff-Linberg
excision of the scapula for sarcoma. 51. Pack GT, Crampton RS: The Tikhor- procedure for bone and soft tissue
Ann Surg 1909;50:1-22. Linberg resection of the shoulder gir- tumors of the shoulder girdle. Arch
.I- 46. DePalma AF: Scapulectomy and a dle: IndicatioJ1S for its substitution for Surg 1999;1 34:252-257.
'5; method of preserving normal configu- interscapulothoracic amputation: Re-
56. Rora beck CH: The management of the
ra tion of the shoulder. Clin Orthop cent data on end-results of the fore-
flail upper extremity in brachia! plexus
1954;4:2] 7-224. quarter amputation. Clin Orthop 1961;
:al injuries. J Trauma l 980;20:491-493.
47. Nakamura S, Kusuzaki K, Murata H, et 19:148.
e
al: Clinical outcome of total scapulec- 52. Guerra A, Capanna R, Biagini R, et al:
tomy in 10 patients with primary ma- Extra-articular resection of the shoul-
for
ec-
.,.,
he
l-
,n,
10rs
I of
mi-
n
976;
)Om
era-
est-

Amputations About the Shoulder:
John M. Miguelez, CP
Randall D . Alley, CP
Introduction
The prosthetic rehabilitation of an crucial aspects of the rehabilitation not only the socket design but also
indjvidual with a humeral neck, gle- process, because this is when informa- the con trol strategy. The extent of
nohumeral, or interscapulothoracic tion is gathered, both clinically and contralateral limb loss, deficiency or
level of absence has traditionally been through open dialogue, that serves as other involvement, and the degree of
a significant challenge to the rehabili- the basis for subsequent rehabilita- function present should be noted. All
tation team, often resulting in poor tion. Failure to devote sufficient time the considerations iliat apply to the
success rates. Each of these levels is and focus to the preprosthetic phase ipsilateral remnant are relevant to the
anatomically unique, but the overall has directly contributed to the histor- contralateral limb, as harnessing de-
approach to the prosthetic manage- ically suboptimal prosthetic success sign and control strategies must in-
ment is sin1ilar (Figure 1). This chap- rates for individuals with limb ab- corporate contralateral involvement.
ter describes the three phases of sence or amputatio n at the gleno- Lower limb deficiencies also play a
prosthetic management that are criti- humeral and associated levels. significant role in balance, donning
cal to long-term prosthesis use and and doffing, and general upper limb
patient satisfaction: ( l) the prepros- Assessment component selection. For example,
thetic phase, during whlch the pros- Initially, the pract1t1oner should the prosthesis for an individual with
thetic rehabilitation plan is formu- record not only t he level(s) and an upper limb deficiency who uses a
lated; (2) the interim phase, during side(s) of involvement but also cane or a walker should have suffi -
which the diagnostic prosthesis, whether or not a loss of dominance cient prehensile grip to withstand the
which evolves into the definitive occurred. An overall health assess- forces applied to these balance aids.
prosthesis, is created; and (3) the ment should be made, and particular Myotesting is important to deter-
postprosthetic phase, during which attention should be paid to cardiac mine the feasibility of using myoelec-
the focus is on prosthetic refinement and associated circulatory healtl1 be- tric control. The information myo-
and training. T he systematic method cause such proximal levels of limb testing provides is also important as a
of care described in this chapter can loss require the user to expend con- feedback tool for teaching and train-
maximize the patient's prosthetic re- siderable effort during operation of a ing and is a quantifiable assessment of
habilitation potential. body-powered or hybrid prosthesis. patient progress. The interaction of
Ipsilateral considerations include the the myoelectric signals during agonis-
cause of absence, the date and extent tic and antagonistic contractions in
Preprosthetic Phase of injury if applicable, tissue condi- each relevant muscle or muscle group
The preprosthetic phase includes the tion, range of motion and strength must be assessed, not simply the am-
physical assessment of the patient, a (for gross movement as well as ilie plitude of a single channel in isola-
thorough consideration of prosth etic myoelectric signal), and any associ- tion. (Agonist and antagonist are
design criteria, a discussion of pros- ated discom fo rt or sensitivity related loosely defined here as they relate to
thetic options and components, and, to the region, whether from contact prosthetic function, which may or
finally, the formulation of the pros- presstu·e, potential weight bearing, or may not differ from physiologic func-
thetic rehabilitation plan. The physi- motions required for operation of the tion, depending on the muscle or
cal assessment of the individual with prosthesis. All of these elements are muscle groups involved.) Finally, tl1e
upper limb absence is one of the most vitally important when considering practitioner must define the optimal

joir
: pos
hel1
tasJ.
the
has
tral
wit
joir
anc
spa
Th<
vat1
the
Figure 1 Typical clinical presentation of residual limb at the humeral neck (A), shoulder disarticulation (B), and interscapulothoracic
levels (C).
der
mo
anc
from family, friends, or others should htuneral or associated level. The pres- thr,
be considered. Any prior prosthetic ence of an occupational therapist pul
experiences, such as the option used, during the assessment is very helpful pul
the socket design, and the patient's u1 the psychological, physical, and cha
perception of its effectiveness, com- psychosocial preparation of the indi- The
fort, and ease of use should be dis- vidual. Preprosthetic therapy should exc
cussed and noted. include strength training of the ipsi- mo
The patient's level of cognitive lateral side, the contralateral upper
ability may also limit the options ap- limb, and the lower limbs; mainte- req
propriate for successful prosthetic nance and enhancement of range of elb,
use. Therefore, another goal of the motion; desensitization techniques; At
evaluation is to understand the vari- edema control; and, if necessary, arn
ous control schemes and their cogni- wound care. ma
tive demands on the user. Unfortunately, patient information llllJ
The vocational and avocational on the various aspects of upper limb cur
pursuits and personal desires of the prosthetics is limited. Therefore, the P°'
Figure 2 lnfraclavicular socket showing mu
electrode placement.
individual must be discussed thor- practitioner should spend consider-
oughly during the patient assessment. able time educating the patient about no1
Individuals with similar levels of limb the basics of casting, fabrication, de\
placement of electrodes within socket absence may require completely dif- delivery, postprosthetic procedures, of
confines, taking into consideration ferent strategies to attain a successful available technology, and potential sio:
comfort from electrode contact pres- result. In addition to the obvious functional gains and other attributes cor
sure and the consistency of contact physical issues of choosing suitable for each option. ava
under varying conditions (Figure 2). components, psychological and psy- exc
This is discussed more fully later in chosocial elements must be consid- Components ate
this chapter. ered carefully when designing the Regardless of the prosthetic option or ma
The prosthetist should discuss the appropriate prosthesis. 1 T he loss or control strategy selected, prostheses dee
limitations of terminal devices and absence of a limb at any level, for these levels require components at bef
other components to help the patient whether from an acquired amputa- the shoulder, elbow, and wrist as well lev,
develop a realistic set of expectations. tion or congenital deficiency, dramat- as a terminal device. The three basic les:
The tendency to become "one- ically affects an individual's body shoulder joint options are nonarticu- po,
handed" and overuse the unimpaired image and self-esteem, and this psy- lated, friction, and locking. In some an
limb should be discussed during the chological impact should be a pri- situations, such as for children or for
assessment. Important prosthetic de- mary focus of the evaluator. the patient requiring an activity- tio
sign considerations include whether Therapeutic i_ntervention during specific prosthesis, a nonarticulated dis
USf
donning and doffing will be assisted the preprosthetic, interim, and post- shoulder is preferred because this
or unassisted and whether any move- prosthetic phases is critical to the minimizes the added weight, bulk, usi
ments are to be avoided during this prosthetic rehabilitation of the indi- and complexity of this portion of the pe1
process. The availability of assistance vidual with absence at the gle1~0- artificial limb. A friction shoulder pa1

Chapter 21: Amputations About the Shoulder: Prosthetic Management 265
joint (Figure 3) allows the patient to lope. The selection of a wrist unit is
position the arm in space, which is based on the functional requirements
helpful for eating, self care, and other of the patient, not the level of ampu-
tasks. The friction shoulder joint is tation or deficiency.
the simplest articulated joint, but it Hooks generally have been consid-
has the disadvantage that the con- ered more functional than body-
tralateral limb must be used to assist powered hands. The prehension pat-
with positioning. A locking shoulder tern was considered superior for
joint allows the patient to position activities of daily living that involve
and then lock the humeral sectiorn in precision. In addition, patients and
space, permitting bimanuaJ activities. rehabilitation professionals preferred
The locking mechanism can be acti- hooks because of their more rugged
vated by using a nudge control with design and usefulness for heavy-duty
the chin. Biscapular abduction, shoul- activities. The preference for hooks is
:ic der elevation, and humeral remnant especially pronounced with body-
motion including flexion, extension, Figure 3 lnfraclavicular socket with pas-
powered prostheses because body- sive ball-and-socket friction shoulder
and abduction can be captured powered hands provide less grip force joint.
:s- through a harness system to activate a and require significantly greater ex-
ist pull switch. The n udge lever and the cursion and force to operate. There-
u1 pull switch are offered in either me- fore, patients with these high levels of have experienced complete loss of tl1e
1d chanical or electric locking versions. absence often find body-powered arm or who were born with such
ii- The latter requires significantly less hands difficult to operate because of high-level absence may find the d is-
1ld excursion and force but is heavier and the inherently short lever arm of the comfort of high-level prostheses too
si- more complex. residuum at these levels. Because great an obstacle to overcome. The
•er Far more excursion and force a.re loss of tactile sensation caused by
electric-powered hands offer in-
re- required to activate a body-powered wearing a socket can be another rea-
creased grip force yet require less
of elbow than a n electric-powered one. gross body motion to operate, they
son for rejection of a prosthesis.
es; At these high levels, the skeletal lever Many high-level amputees find that
have been used more widely during
ry, arm is sufficiently compromised that an active prosthesis offers only lim-
the past several decades for individu-
many patients find it difficult, if not ited fu nctionaJ advantages.
als with amputations and deficiencies
on in1possible, to produce sufficient ex-
at these levels. Passive Prostheses
nb cursion to fully flex and lock a body-
he powered elbow. Without the use of a Prosthetic Options Many types of passive prostheses are
er- multiposition elbow, the amputee can- designed for individuals with high
It is imperative to discuss the pros-
>Ut not effectively position the terminal levels of limb absence (Figure 4), in-
thetic options available to facilitate
)fl, device in space to accomplish activities cluding shoulder caps, which are of-
the patient's participation in the re-
·es, of daily ljving. In the past, an excur- ten used as cosmetic restorations at
habilitation process. Primary pros- tl1e shoulder disarticulation and in-
ial sion amplifier was sometimes used to
thetic options include independence terscapulothoracic (ISO term: fore-
tes compensate for the reduced excursion
without a prosthesis, use of a passive quarter) levels. The most common
available at these levels. The improved
prosthesis, or use of an active pros- reasons an individual with a hi.gh-
excursion required the user to gener-
ate increased force, however, which thesis. Active prostheses can be fur- level loss opts for a passive prosthesis
many found objectionable. In recent ther classified by the control method over an active one are reduced weight,
or
decades, electric-powered elbows have provided: body-powered, externally improved cosmesis, and reduced en-
ses
been more widely used for such high- powered, or a hybrid system combin- ergy and cognitive requirements. Ini-
; at
level fittings because they requjre far ing both body- and externally pow- tial, maintenance, and repair costs are
fell
less effort to operate than does a body- ered components. Some patients pre- typically lower than for other types of
1sic
powered component, with or without fer an activity-specific prosthesis prostheses, although a high-definition
cu-
an excursion amplifier. optimized for one task. These devices silicone restoration may be more ex-
me
The four basic wrist uruts are fric- may incorporate active or passive ter- pensive tllan a simple mechani.caJ
for
tion, locking, flexion, and quick- minaJ devices. prosthesis. The passive prosthesis of-
lty-
ted disconnect. A wrist unit allows the fers little or no pinch force. Some pas-
user to position the terminal device
Independence Without a sive prostheses have embedded wires
:his
Jlk, using the contralateral hand or com- Prosthesis in the hand component that allow
the pensatory gross body movements, ex- The choice not to wear a prosthesis is prepositioning of the prosthetic d igits
der panding the user's functional enve- an important option. Individuals who by shaping the fingers manually.

+,
for
ele,
bo,
ter
ter
vol
do
of
th€
CO!
tor
va1
bo·
fie:
th€
fro
Figure 5 Example of a body-powered tlu
prosthesis w ith cable-operated elbow Ali
and hand. The shoulder and wrist are
ref
Figure 4 Example of a passive prosthesis; passive friction joints.
be,
harness for suspension is not pictured.
ne,
sys
(Active) Body-Powered a contraindication for individuals
op
Figure 6 Example of a hybrid prosthesis
Prostheses whose capacity has been diminished with locking shoulder joint, body- de·
as a result of disease or medications, powered elbow, and externally powered
Operating body-powered prostheses
for those who have contralateral in- wrist and terminal device. (A
at the humeraJ neck, glenohumeral,
volvement, or for the elderly, who
and interscapulothoracic levels pre- P<:
may simply not possess enough
sents a daunting challenge: generating Elf
strength for adequate function. 3 In costs for body-powered prostheses are
enough force and excursion to acti- mi
addition, cosmetic appearance is lun- almost invariably less than for their
vate the body-powered elbow, wrist, COi
ited, at best, and the gross body electric-powered counterparts.
and hand components (Figure 5). Be- blt
movements required for actuation
cause of the absence of the skeletal le- (Active) Hybrid Prostheses an
call attention to the artificial limb.
ver arm and limited available excur- wJ
One of the most significant advan- A hybrid prosthesis has both body-
sion, the functional envelope is tages of a cable and harness system is powered and electronic components. fot
significantly reduced. Maximwn el- the inherent feedback. The commonly The most common configuration op
bow flexion is often difficult to used hook terminaJ device allows for incorporates a body-powered elbow ele
achieve, as is any amount of abduc- greater visibility when acquiring, ma- and electric-powered terminal device fo1
tion, because of the absence or lim- nipulating, or grasping objects. Body- (Figure 6). Hybrid prostheses offer an
ited length of the humerus. powered prostheses are more durable the advantages of both body-powered joi
The harness that is used at this than are electric-powered prostheses. and electric-powered prostheses while Ill!
level must provide maximum effi- Body-powered prostheses weigh less, minimizing their disadvantages. Hy- fw
ciency and hence is often fairly re- a nd this weight is distributed more brid prostheses are a viable option
strictive. Users may find it uncom- optimally than it is in most hybrid even for patients with amputations va:
fortable, especially in the contralateraJ and electric-powered designs. Body- at the hwneral neck and higher when ofl
axilla, whkh is often used as an an- powered elbows can be flexed more adequate strength and excursion re- alt
chor point. Compression of the nerve rapidly than electronic elbows, aJ- main. av:
bundle in this region can result in though at extremely high levels the Combining the two types of con- tic
nerve entrapment syndrome, in lack of sufficient excursion may ne- trol has several potential advantages. tic
which anesthesia can occur if a sen- gate this potential advantage. The use of an electronic terminal de- el€
sory nerve is affected, and paralysis if Harness and cable systems do not vice reduces the harnessing n eeded ca:
a motor nerve is involved. 2 require battery charging, installation, because body-powered motion is re- SO·
Significant energy expenditure is or removal, or the dexterity and the quired only to flex the elbow. The pe
also required to operate a body- cognitive ability required to perform functional envelope is enlarged in be
powered prosthesis at these proximal these operations. Finally, the initial, many instances, particularly when ev
levels of limb absence. This can be maintenance, repair, and replacement myoelectric control is feasible. Pinch ha

force is also much greater with an

electronic device than is possible with
body-powered, voluntary-opening
terminal devices. Also, an electronic
terminal device usually provides both
voluntary opening and voluntary
closing, a more natural reproduction
of human hand movement. Operating
the terminal device via myoelectric
control is believed to improve muscle
tone and reduce disuse atrophy. Ad- Figure 8 Activity-specific terminal device
vantages of the body-powered el- for playing billiards. (Courtesy of Bob
Radocy.)
bow are that it provides more rapid
flexion/extension movements, giives
the user important sensory feedback worn on a sustained basis. At the gle-
from the harness forces, and reduces nohumeral level, the key to achieving
the overall weight of the prosthesis. stability is a n intimately fitted socket
Also, the initial, maintenru1ce, and that provides rigidity in load-bearing
repair costs of the system are iless Figure 7 Example of an externally pow- areas and serves as a secure platform
because an electronic elbow is not ered prosthesis with locking shoulder for anchoring components.4
joint plus myoelectric elbow, wrist, hand, Individuals with amputations and
needed. Finally, a hybrid control and interchangeable electronic lock ter- absences at the glenohumeral and as-
system can encourage simultaneous minal device.
sociated levels have reported many
~sis operation of the elbow and terminal
problems with long-term prosthesis
dy- device.
red maintenance requirements, and oper- use. Frequently mentioned issues in-
(Active) Externally ation of the primary and secondary clude the weight of the prosthesis,
electronic controls can impose a sub- heat buildup within the socket, lack of
Powered Prostheses
stantial cognitive demand on the user. stability, reduced control of the termi-
Electric-powered components mHu- Despite these disadvantages, many in- nal device in certain planes and body
are
1e1r mize the energy expenditrne and dis- dividuals with glenohumeral-level ab- positions, and difficu lty in indepen-
comfort associated with a control ca- sences do well with completely elec- dent donning. The socket design must
ble and harness (Figure 7) . Both static tronk prostheses. distribute the load primarily over al'-
5 and dynamic cosmesis are improved eas with sufficient tissue padding
jy- when a control cable is not required Activity-Specific Prostheses while eliminating excessive pressure
1ts. for either terminal device or elbow Activity-specific devices include recon skeletal protuberances. Heat
LOO
operation. Like hybrid systems, a myo- reational prostheses and those de- buildup while wearing a prosthesis is
OW
electric system offers increased pinch signed to facilitate work tasks or directly related to the amount of skin
,ice force, voluntary opening and closi ng, activities of daily living. Activity- covered by the socket and the result-
ffer and, although a prosthetic shoulder speci fie prostheses are very effective ing lack of heat dissipation. There-
red joint permits only passive positionin accomplishing the specific tasks for fore, reducing the surface area of the
1ile ing, the potential for an even greater which they are designed. Because socket can greatly improve comfort
:iy- functio nal envelope. these prostheses usually require only and patient acceptance. Lack of sta-
ion A myoelectJ"ic elbow has the disad- simple controls and minimal compo- bility and reduced control of the ter-
ons vantage of lacking the direct feedback nents, they aTe often less costly than minal device in certain planes and
~en offered by a harness and cable system, more complex designs (Figure 8). The body positions are both results of a
re- although indirect feedback is still chief disadvantage of an activity- socket that changes position during
available based on input effort, dura- specific prosthesis is that it has lim- movement. Without a stable socket,
on- tion of supplied signal, elbow vibra- ited utility. Interchangeable activity- the efficiency of the harness system is
ges. tion, and sound. The weight of a fully specific prostheses can help to address greatly reduced. Consequently, the
de- electronic system is considerable, and this limitation. wearer must produce more gross
ded care must be taken to ensure that the body movement to operate the pros-
re- socket provides at least partial sus- Design Considerations thesis, resulting in increased fatigue
Ihe pension to minimize the weiight The foundation for successful pros- and frustration . With improved
in borne by sensitive areas. In addition, thesis use is the socket. Unless the socket stability, a less complex harness
hen every externally powered prosthesis socket is comfortable and securely system may be sufficient, which facili -
nch has battery installation, removal, and suspended, the prosthesis will not be tates the donning process.

during which the status and the cla,

evolving goals of the patient are dis- Thi
cussed and the plan modified as nec- soc
essary. lint
bui
har
Interim Prosthetic bili
Phase the
Aher a thorough prosthetic and ther-
wit
apeutic rehabilitation plan has been
sig1
form ulated, the interim prosthetic
Jig}
phase starts. During this phase, the
du
prosthesis is created and therapy tran-
the
sitions from general residual limb cla·
preparation to specific prosthetic
Figure 10 Body-powered socket design mo
covering less of the torso surface area training. Therapy could include elec-
hu1
than did early designs. tromyographic (EMG) site selection am
and specific muscle differentiation for tro
Figure 9 Early body-powered socket de- members of the rehabilitation team, a myoelectric prosthesis or further res
sign demonstrating extensive coverage of shoulder complex strengthening for
including the physician, the physical ter
the ipsilateral torso.
and occupational therapists, the psy- body-powered compoDents. This eve
chologist, and the rehabilitation coor- phase also includes the cast impres- tau
To create an effective prosthesis, dinator, should be concmrent with sion, creation of a diagnostic prosthe-
the prosthetist must be able to assess the prosthetic assessment. Interaction sis, and the assessment of functional sig
the many design criteria both individ- and communication among rehabili- use of the diagnostic prosthesis, and it ICU
ually and as they relate to one an- tation team members is critical to concludes with fabrication and deliv- ces
other. The harness system must be de- success at these levels. Once all mem- ery of a definitive prosthesis. The di- she
termined during the preprosthetic bers of the rehabilitation team have agnostic prosthesis ensures that opti- we
phase, as this will influence the socket offered their recommendations, a fi- mal socket fit and comfort and lie:
nal rehabilitation plan can be form u- prosthesis control/function , align- tor
design. T he harness is especially criti-
lated. The recommendations must ment, and definitive fabrication spec- sea
cal in bilateral deficiencies or when
take into account the patient's physi- ifications have been achieved. fficl
significant areas of scarring or skin
cal capacity and willingness to com- The type of prosthesis control cho- loa
graft are present. With amputations at
mit to what is often a rigorous fitting sen influences socket design and soc
the humeral neck (see Case Study 2),
and training schedule.5 A patient who should therefore occur before an im- ab]
the remnant humerus can often be
has a sense of control and active par- pression of the patient's residual limb tio
used for primary or secondary con-
ticipation in the formulation of the is taken. Regardless of which pros- fra
trol strategies, which may affect com-
rehabilitation plan is more likely to thetic option is selected, all gleno- no
ponent selection and socket design.
put forth the effort necessary to exe- humeral and associated level prosthe- otl
FinaUy, it is important to clarify the
cute the plan successfully. ses require a stable and comfortable cla
patient's cosmetic expectations for the thi
The rehabilitation plan integrates socket to support the prosthetic
prosthesis because these consider- de:
the patient's prosthetic, therapeutic, shoulder, elbow, wrist unit, and ter-
ations may also affect component se- ca1
psychological, and medical needs minal device components.
lection, socket design, control strate- co:
based on short- and long-term goals.
gies, and long-term acceptance. The
Prosthetic options affect occupational Socket Design tio
optimal socket is the one that bal-
therapy, physical therapy, and psy- Despite differences in anatomy, socket
ances these interrelated goals to meet Di
chological counseling.6 One of the designs for humeral neck amputa-
the needs of the individual amputee. tions, glenohumeral disarticulations, Tb
greatest challenges is orchestrating
the interaction of the various services. and interscapulothoracic-level ampu- ne
Formulation of the Sta
When treatment team schedules are tations are similar and have gradually
Rehabilitation Plan not coordinated in advance, lapses evolved to cover less of the torso. pa
The preprosthetic phase culminates in care can delay the rehabilitation Early socket styles, which contained 1111
with the formulation of a detailed process and lead to patient frustration aU of the shoulder girdle and covered po
SU
prosthetic rehabilitation plan. Com- and discouragement. Progress evalua- much of the trunk, were bulky and
ev,
prehensive evaluations by the other tions should be scheduled regularly, hot and sometimes in1pinged on the

:he clavicle or acromion 7'8 (Figure 9).

lis- These early designs were replaced by
ec- sockets with more abbreviated trim-
Jjnes that reduced weight and heat
buildup9 (Figure 10). More e>.1:ensive
harnessing was often required to sta-
bilize the prosthesis, however, despite
the smaller surface area of the socket.
Sin1pson and Sauter are crecLited
er- with the next evolution in socket de-
:en sign, the Perimeter Frame. 10 Made of
:tk lightweight aluminum, this socket in-
the cluded large windows, or "cutouts;' in
lll-
the anterior, posterior, and acromio-
:n b clavicular regions (Figure 1 l ). By
:tic moving the acromioclavicular area or
ec- humeral neck inside the socket, t he
ion amputee could activate switches con-
for trolling electronic devices with good Figure 12 The prosthetist applies down-
her results. Myoelectrodes in the Perime- ward force to the humeral segment,
for ter Frame had limited success, how- Figure 11 Perimeter Frame-type socket. demonstrating t he stability achieved w ith
his ever, because it was difficult to main- A, Anterior view. B, Posterior view. this infraclavicular socket design.
es- tain skin-to-electrode contact. 11
l1e- In the 1980s, infraclavicular de-
nal signs were developed. L2 The infraclav- pressure is not applied to any single hwneral and associated levels, range
:l it icular design differs from its prede- area. of motion and associated excursion
~v- cessors because it does not enclose the Diagnostic assessment also focuses are often insufficient for effective
di- shoulder complex to support the on the identification and verification control of a fully body-powered pros-
,ti- weight of the prosthesis. Instead, it re- of sufficient EMG signal recognition thesis. This is even more problematic
md lies on compression of the deltopec- for myoelectric control, sufficient for children and for people of slight
~n- toral muscle group anteriorly and the capture of excursion for body- build or with narrow shoulders.
ee- scapular region posteriorly. 13 Inti- powered control, or both for hybrid Once the controls have been con-
mate anatomic contouring of these control. An experienced therapist is firmed, the components can be
10- load-bearing areas stabilizes the extremely valuable in assisting the pa- mounted and aligned. The location
md socket on the torso (Figure 12), en- tient and practitioner with locating and angles of abduction/adduction
m- abling the wearer to effectively posi- and strengthening specific muscle and internal rotation of the shoulder
mb tion the terminal device in space. In- groups. When myoelectric control is joint should mirror the center of the
os- fraclavicular sockets are also less selected, the diagnostic socket should contralateral shoulder. With humeral
10- noticeable under clothing than are be carefully examined for consistent neck-level amputations, the mechani-
he- other designs. Because the acromio- skin contact, especially during con- cal shoulder joint location may not be
ble clavicular complex is not encased in traction of the desired control mus- anatomic, to avoid creating a prosthe-
~tic this design, it is free to move indepen- cles.16 Some myoelectric systems sis with obvious shoulder asymmetry.
:er- dently of the socket. This movement require the patient to quickly cocon- For patients with cosmetic concerns,
can be used to activate secondary tract antagonistic muscles to control one solution is to mount the shoulder
control inputs to control wrist rota- functions such as unlocking the elbow joint inferior to the distal aspect of
tion, shoulder or elbow locks, etc. 14 • 15 or transferring control from the ter- the humeral neck (Figure 13).
ket minal device to an electric wrist rota- After aU components have been at-
1ta- Diagnostic Assessment tor. 17 Some patients have difficulty tached and aligned, reliable control of
,ns, The cLiagnostic socket with the har- contracting both targeted control the shoulder, elbow, wrist, and termi-
:JU- ness affixed should be assessed both muscles simultaneously and will renal device should be verified. Second-
:1lly statically and dynamically whiie the quire either therapy training or a dif- ary control options, including a re-
:so. patient is standing, sitting, and bend- ferent control scheme. When body- mote on/off, shoulder lock, elbow
1ed ing forward and to the side. It is im- powered control is provided, the unlock, and wrist rotation, require
red portant to evaluate the load-bearing socket should be evaluated for maxi- analysis of gross body movement and
md surfaces and ensure that forces are mwn range of motion to determine selection of appropriate input op-
the evenly distributed so that excessive optimal excursion. At the gleno- tions, often push- or pull-type

Figure 14 Child with high-level congeni-

tal deficiency. Note the contour of t he af-
fected side compared with t he contralat-
eral shoulder.
Figure 13 Diagnostic prosthesis w it h

the shoulder joint located inferior to t he of motion should be assessed care-
humeral neck. fully to ensure that accurate duplica- Fig
tion of the diagnostic prosthesis has ter
Th,
been achieved. Controls and adjust- Figure 15 Surgical remova l of t he proxi-
switches. Push switches can be acti- ne.
ments should be verified to optimize mal humerus resu lts in a sensate arm
mi·
vated with the chfo, with elevation of function. This could include snugging w ith f unctioning musculature that hangs
t hE
the acromial complex, or with move- at t he patient's side. Firing the biceps re-
the harness of a body-powered com- sults in telescoping of the humeral soft
ment of the humeral neck. Pull ponent or fine-.tun Lng the electronics tissues but not in elbow f lexion.
switches are attached to the harness for a myoelectric device. sh,
and are activated by excursion of the The patient's perceptions are criti- sp,
harness. Verifying control isolation cal to the process. A prosthesis that is beneficial. This is especially true ca1
(after each control option is added) for the glenohumeral-level amputee sh,
may appear to fit and function well
ensures that inadvertent activation of because the loss at th is level is so
from the rehabilitation team's per-
a particular function does not occur. significant.
spective will still not be successful if it S1
Before creating the definitive pros- Occupational therapy becomes the
does not meet the patient's require- C,
thesis, the prosthetist must determine focal point of the postprosthetic
ments. For example, the harness may
the socket .material and thickness, phase. The goal of postprosthetic Cc
seem too tight or the patient may feel
frame color and composition, trim- therapy should be the integration of
that too much effort is required or Ac
lines, and mounting locations for sec- the prosthesis into the patient's life-
that cosmetic issues have not been ad- ab.
ondary control inputs. This is best ac- style. The therapist begins with spe-
equately addi-essed. Responding to ha
complished while the patient is
such concerns with specific changes cific controls training: flexing and po- th,
wearing the diagnostic prosthesis. The
and involving the patient in the sitioning the elbow, opening and fer
prosthesis is ready for final fabrica-
decision-making process gives a sense closing the terminal device, and supi- uri
tion when all issues of comfort, con-
trol, function, cosmesis, and fabrica- of empowerment and increases the nating and pronating the wrist. With oft
tion have been thoroughly addressed. likelihood of a positive Jong-term guidance and practice, the patient will Tb
By following this protocol, few w1an- outcome. master these skills and then translate th<
ticipated issues will arise during the Another important responsibility them into task-specific activities. en
delivery of the definitive prosthesis, of the rehabilitation team is to help During this process, it is important me
and alterations should be minin,al. the patient develop realistic expecta- that the therapist and prosthetist shi
tions. When the definitive prosthesis maintain consistent communication th<
is delivered, the patient must confront to ensure seamless rehabilitation. Of- th<
Postprosthetic Phase the limitations of a prosthesis. Even ten the prosthesis requires minor sul
Prosthetic delivery is the culmination the best-designed prosthesis cannot adjustments as new tasks are under- shi
of much hard work by the patient and replace the function of a human arm. taken or to address residual limb vol- sh.
the rehabilitation team and can be This can often be an emotional tinle, ume changes. Care and maintenance gle
quite gratifying. Once the prosthesis and access to a support network that of the prosthesis, including cleaning de
is donned, the fit, function, and range includes a psychologist or counselor the prosthesis and personal hygiene, CO:

is ~
.\
igure 18 Although active flexion be-

:>nd 90° is impossible, the left hand can
,sist the unimpaired limb in light tasks,
espite the absence of the humerus.
A locking elbow orthosis is not of

1uch use because the skeletal loss
iakes the humeral section unstable. Figure 16 Clear test socket has a perime-
ter socket that is stabilized on the torso. Figure 17 The finished "prosthesis" al-
iomechanically, it is necessary to lows the patient to actively f lex and ex-
The posterior humeral shell is articulated
reate a prosthetic socket-like struc- roxi- tend the elbow for desktop activities. The
near the glenohumeral joint region, per-
.ire on the chest to stabilize the arm arm mitting the patient to passively abduct lightweight padded shell restores shoul-
1pport, and many patients rejecl de- angs der symmetry under clothing.
the arm for sitting at a desk or table.
ices that extend from the torso to the ,s re-
soft
•rist. In some instances, a posterior
umeral trough connected to a Lorso should also be discussed. Finally, a lntercalary Amputation . .
latform can provide sufficient coun- specific plan for long-term follow-up lntercalary amputations, which are
:rforce to permit the patient to vol- true care and component maintenance rarely encountered, are extremely
ntari ly flex and extend the arm for •utee shou ld be formulated.
challenging for the prosthetist-
esktop activities (Figures 16 through .S SO
orthotist to manage. One example is
8). Articulated devices, whether
ody-powered or electric-powered,
Special the Tikhoff-Linberg resection, where
s the much of the humerus is removed but
re not always successful for this pop- hetic Considerations the balance of the upper limb remains
lation because the intact forearm he tic C'"'ngenital Absence sensate with intact musculature. It is
11d hand weigh much more than m of a
Acquired amputations and congenital tempting to consider these patients as
'ould a hollow prosthetic forearm v
life- absences at the glenohumeral level having a loss similar to a brachia]
~gment. spe- s
have distinct clinical presentations p lexus injury, but prosthet.ic solutions
d po- that affect prosthetic management dif- that arc successful for brachia! plexus
:ase Studies and ferently. Will1 congenital absence (Fig- injuries often fa il with this population. 4
:a«-e ct, ·dy 1 supi- ure 14), the clavicle and scapula are The overwhelming functional deficit (
With often misshapen and may be fused . is the complete loss of internal skeletal j
22-year-old man incurred a bra-
It wiJJ They are usually foresho rtened, and stability. As a consequence, when the
1ial plexus injury secondary to a wa- (
nslate the lateral aspects are swept upward, patient fires the elbow flexors, the arm
:r skiing accident, resulting in a flail
vi lies. creating a prominent and usually very shortens but the forearm does not a
mi . Eight years after the injury, after
1ul tiple surgeries to attempt neural
)ftant mobile bony spur. 18 The rest of the reach a horizontal position, as shown
J1etist shoulder area is often fleshy and has in Figure 15. Because the forces gener- r
:construction, the patient elected to
ndergo a shoulder disarticu lation. ::ation the potential for weight support, but ated by the upper arm musculature are l
he residual limb/shoulder girdle had n. Of- the lack of bony structures often re- considerable, it is virtually impossible 1
ealthy skin without scar or graft tis- minor sults in problems witl1 stability. The to create an external "prosthosis" that t-
1e. However, the pectoralis muscle I rnder· shoulder profi le drops away quite w ill prevent such telescoping from oc- s
as significantly atrophied secondary .b vol- sharply from the bony point of the curring.20 In addition, it is impossible \'
> the brach ia! plexus injury and pro- :nance glenoid area, and a prosthetic shoul- to carry even very light objects in the
uced a 13-µV maximum EMG sig- eaning der joint can be incorporated w ithout hand because the entire arm is con- c
..... 1 Tl.... ,.. ........... ,,..,.. ..... r ............... ,.1 .... 4
• __... ....... • ............ . ...... . . ,n-i.PnP . COSmPtir "r ll'rhn ir<> l rliffir11ltv l9
\11Jtncm1 \u d,1111· o/ Ortlwpn ·cit[ 'itirgt'ons

se.
de
s
Re:
an
SIU
an
so
pc
av
nc
an
by
co
oc
Figure 20 Individual with bilateral ampu- gi:
tations, at the humeral neck and at the a
Figure 19 Definitive myoelectric prosthe- transradial level. SU
sis for an individual with shoulder-level n
brachia! plexus injury. Case Study 2 Figure 21 Definitive hybrid prosthesis for ha
A 39-year-old man presented 5 years an individual w ith bilateral amputations, tic
at the humeral neck and transradial level. tic
postinjury with bilateral amputations
extremely limited. The infraspi natus Note the position of the shoulder joint
(left side, transradial level; right side, fu
muscle produced an EMG signal in humeral neck-level) secondary to an be
excess of 70 µV. The patient reported The patient used ballistic body move- Vi c
electrical burn (Figure 20). The right
overuse of his surviving hand and ments to flex the prosthetic elbow and m,
residual limb/shoulder girdle exhib-
wrist and had a strong interest in humeral neck abduction/flexion to th
ited minimal scar and graft tissue and
maximum function with a good cos- control the elbow locking mechanism,
good range of motion and strength of fo
metic appearance. eliminating the need to route harness
the humeral neck. However, the left straps for elbow flexion across the
The patient was fitted with an infra-
clavicular socket using myoelectric
side (transradial level) had extensive fragile axilla region. The infraclavicu- A
scar and graft tissue in the areas of lar socket permitted independent
control to operate an electric elbow,
the scapula, pectoralis, deltoid, and n
Jocking of the cable-operated elbow
hand, and wrist rotator, plus switch
axilla, which limited the ability to an- because the humeral neck was not
w
control of an electric locking shoulder m:
chor the control/suspension harness contained within the socket.
joint. The infraspinatus muscle site an
was used to proportionally control el- for the humeral neck- level prosthesis The left side (transradial level) was
bow flexion and terminal device clos- through the axilla region. The patient fitted with a self-suspending myo-
ing, allowing precise positioning of had adequate EMG signals on both electric prosthesis with an electronk R
the elbow and fingers. The weaker residual limbs, in excess of 80 µV. The wor.k hook and wrist rotator control. l
pectoralis muscle was used to provide team's focus was on obtaining patient Myoelectric control offered enhanced
single-speed control of terminal de- independence, reducing prosthesis grip force and enlarged tl1e functional
vice opening. To decrease the weight weight and heat buildup, increasing envelope compared with the patient's
of the prosthesis and reduce heat grip force, enlarging the functiona l previous body-powered prosthesis. By
buildup, the socket trimlines were ab- envelope, and limiting shear forces on using a special donning aid incorpo-
breviated and a window was cut infe- the scar and graft tissue. rating a weighted, extra-long lanyard,
rior to the axilla. The resulting pros- On the right side (humeral neck- the patient learned to don the transra-
thesis allowed t11e patient to perform level), the patient was fitted with a hy- dial prosthesis independently by using
bimanuaJ activities with a grip force brid prosthesis that used myoelectric his legs and feet to man ipulate the lan-
in excess of 20 lb. The forearm and control of electronic work hooks and yard . He then could use the transradial
hand were covered with a custom sili- wrist rotators, plus cable-operated myoelectric prosthesis to don the
cone synthetic skin to closely resem- control of an elbow with a forearm prosthesis on the opposite side. The
ble the contralateral limb and to ad- balancing unit (Figure 21). The cable- increased grip force, larger functional
dress the patient's concerns regarding operated elbow significantly reduced work envelope, and independent don-
body image (Figure 19). tl1e overall weight of the prosthesis. ning characteristics of these prostbe-

ses have allowed th is patient to live in- of Adults and Children With Upper Ex- l2. Sears HH, Andrew JT, Jacobsen SC:
dependently in the community. tremity Amputation. New York, NY, Experience with the Utah arm, hand,
Demos, 2004, pp 125-126. and terminal device, in Atkins DJ,
2. Reddy M: Nerve entrapment syn- Meier RH (eds): Comprehensive Man-
summary drome in upper extremity contralat- agement of the Upper Limb Amputee.
Recent improvements in components eral to amputation. Arch Phys Med New York, NY, Springer-Verlag, 1989,
Rehabil 1984;65:24-26. pp 200-201
and control options have achieved
3. Mckenzie DS: Powered prosthesis for 13. Alley RD, Sears HH: Powered upper
successful prosthetic fitting of many
children: Clinical considerat ions. lin1b prosthetics in adults, in Muzwn-
amputees with glenohumeral and as-
Prosthet Int 1967;3(2/3):5-7. dar A (ed): Powered Upper Limb Pros-
sociated levels of loss. When body-
4. Alley RD, Miguelez JM: Prosthetic theses. Berlin, Springer-Verlag, 2004,
powered components were the only pp l33-138.
rehabilitation of glenohLtmeraJ level
available option, prosthetic fitting was
deficiencies, in Atkins DJ, Meier RH 14. Miguelez J, Miguelez M: The Micro-
not as successful. A comprehensive (eds): FunctionalRestoration of Adults Frame: The next generation of inter-
and systematic approach, coordinated and Children With Upper Extremity face design for glenohumeral disartic-
by an experienced rehabilitation team Amputation. New York, NY, Demos, ulation and associated levels of lin1 b
consisting of a physician, physical and 2004, pp 244-250. deficiency. J Prosthet Orthotics 2003;15:
occupational therap ists, a psycholo- 5. Atkins D: AduJt upper-limb prosthetic 66-71.
gist, a rehabilitation coordinator, and trainLng, in Atkins DJ, Meier RH (eds): l 5. Daly W: Upper extremity socket de-
a prosthetist can improve long-term Comprehensive Management of the Up- signs. Phys Med Rehabil Clin North Am
success rates with these prostheses. per Limb Amputee. New York, NY, 2000;! I :627-638.
The outcome is best w h en th e patient Springer-Verlag, 1989, p 58. 16. Heger H, Millstei11 S, Hunter G:
:or has a sense of control and active pu- 6. Canelon MF: Training for a patient Electrically-powered prostheses for the
15, ticipation throughout the rehabilita- with shoulder d isarticulation. Am J adult with an upper limb amputation.
el. Occup Ther 1993;47:174-178. J Bone Joint Surg Br 1985;67:278-281.
tion process. Verifying optimal fit and
function of the diagnostic prosthesis 7. Brooks MA, Dennis JF: Shoulder dis- 17. Stern P, Lauko T: A myoelectrically
articulation type prostheses for bilat- controlled prosthesis using remote
before fabrication of the definitive de-
eral upper extremity amputees. Inter muscle sites. Inter Clinic Info Bull 1973;
vice has proved to be an effective
1d Clin Info Bull 1963;2: 1-7. 12: l-4.
method to avoid costly modifications
to 8. Neff GG: Prosthetic principles in 18. Hall C, Bechtol CO: Modern amp uta-
that can result in loss of confidence
m, shoulder disarticulation for bilateral tion technique in the upper extremity.
for th e patient. amelia. Prosthet Orthot Int 1978;2:
!SS J Bone Joint Surg 1963;450: l 717-1722.
143-147. 19. Cooper R: Prosthetic principles, in
he
u- Acknowledgment 9. Wright TW, Hagen AD, Wood MB: Bowker JD, Michael JW: Atlas of Limb
:nt Prosthetic usage in upper extremity Prosthetics: Surgical, Prosthetic, and
The autho rs would like to thank John amputations. J Hand Surg Am 1995;20: Rehabilitation Principles. Rosemont, IL,
)W
W. Michael, MEd, CPO, for contribut- 619-622. Amer ican Academy of Orthopaedic
10t
ing the section on fitting intercalary 10. Neff G: Prosthetic principles in bilat- Smgeons, 2002, pp 271-275. (Origi-
amputatio ns. eral shoulder disarticulation or bilat- nally published by Mosby-Year Book,
ras 1992)
eral amelia. Prosthet Orthot Int 1978;2:
·o- 143-147. 20. Ham SF, Eisma WJ, Schraffordt Koops
1ic References 11. Mongeau M, Madon S: Abstract: Eval- H, Oldboff J: The Tikhoff-Linberg
ol. 1. Alley RD: The prosthetist's evaluation uation prosthetic fitting of 13 shoul- procedme in the trea tment of sarco-
ed and planning process with the upper der disarticulation clients since 2 mas of the shoulder girdle. J Surg
ial extremity amputee, in AtkiJlS DJ, years. JAssoc Child Prosthet Orthot Clin Oncol 1993;53:71-77.
it's Meier RH (eds): Functional Restoration 1990;25:26.
By
,o-
rd,
:a-
ng
.n-
ial
he
'h e
1al
in-

Prosthetic Training
Diane]. Atkins, OTR
Introduction
The amputation of an upper limb in- upper limb amputee are believed to event that myoelectric prosthetic
volves the loss of a hand and therefore depend on multiple factors. These in- components are prescribed), (7) in-
is especially difficult for the patient. clude early posttraumatic interven- form and guide the patient regarding
The hand functions in prehensile action, an experienced team approach, prosthetic components and options,
tivities, as a sensory organ, and as a patient-directed prosthetic training, and (8) explore the patient's goals re-
means of communication. Any loss patient education, and patient moni- garding the future.2
will interfere with the individual's toring and follow-up. Healing of the residual limb usu-
productivity and feeling of complete- This chapter stresses the impor- ally will be essentially complete by the
ness and will alter his or her interac- tance of adhering to good prepros- 21st postoperative day, allowing for a
tions with the environment. 1 thetic and prosthetic training princi- vigorous program of p rosthetic prep-
Each person with an upper limb ples. Listening to and acknowledging aration.3 Malone and associates4 have
amputation is unique, and no two the patient's psychological and func- suggested that the first month after
amputations are identical. Because tional needs is critically important in upper limb amputation is the golden
people are so dependent on their achieving the goals of acceptance of period for prosthesis fitting; ie, pros-
arms and hands, the person with an the prosthesis and successful func- thesis fitting should be initiated dm-
upper limb amputation-particularly tion. ing this time to maximize the level of
a person who has lost both arms-is acceptance and use of the prosthesis.
initially d evastated and unprepared to
perform even a simple task. There- Preprosthetic
fore, rehabilitation of these patients Therapy
can be among the most challenging
and rewarding clinical opportunities The preprosthetic therapy phase be-
for a practitioner. gins when the sutures are removed
Independence in all functional ac- and the wound has healed, generally
tivities is the goal of almost every per- about 2 to 3 weeks after surgery. This
son with an upper limb amputation, program is managed and monitored
and this goal is entirely possible except primarily by occupational. therapy
in very short bilateral transh umeral personnel.
amputations and in bilateral amputa- The goals of the preprosthetic pro-
tions at the shoulder. Every person gram are to (1) promote residual limb
with an upper limb amputation shri11kage and shaping, (2) promote
should be given the opportunity to use residual limb desensitization, (3) main-
a prosthesis, recognizing that it is u lti- tain normal joint range of motion,
mately that person's choice as to (4) increase muscle strength, (5) max-
whether the prosthesis will become a imize self-reliance in the performance
part of his or her daily life. of tasks required for daily living,
Successful outcomes in rehabilita- (6) determine the electrical potential
tion for the unilateral and bilateral provided by various muscles (in the Figure 1 Figure-of-8 wrapping.

276 Section II: The Upp er Limb
Residual Limb Shrinkage her body by practicing desensitization dominance may be necessary. Instruc- lim
regularly. tion in one-handed activities is indi- pm
and Shaping
When complete healing has oc- cated with the unilateral amputee. boc
Shrinking and shaping of the residual The bilateral upper limb amputee
curred, aggressive massage should be (co
limb is perhaps the most critical as- presents a unique challenge. These
performed to prevent adhesions from elec
pect of the preprosthetic program. If patients are totally dependent follow-
occurring and to provide additional obj
this is not done properly, significant
circulation and wound healing prob-
sensory input. The therapist should ing bilateral arm loss, and it is impor- anc
explain that this massage will improve tant to express reassurance, support, anc
lems can occur. and realistic optimism to them during
the amputee's tolerance to the pres- de,
Compression aids such as elastic this time. Independence can be en-
sure that will be placed on the resid-
bandages, tubular bandages, or hanced by a simple device such as a
ual limb by the prosthetic socket. boc
shrinker socks are applied to the re- universal cuff used with an adapted ligl:
sidual limb to effect shrinking and Maintenance of Joint utensil, toothbrush, pen, or pencil. ere,
shaping. A figure-of-8 wrapping
Range of Motion pe11
method is used to apply more pres- Myoelectric Site Testing
The maintenance of joint range of ma:
sure distally than proximally (Figure Electric upper limb components pow-
motion is an essential goal of an ef- elec
1). Elastic bandages should never be ered by myoelectric control sites ru·e
fective treatment program. Maintain- pea
applied in a circumferential manner, being prescribed with increasing fre-
ing scapular, glenohumeral, elbow, less
which can severely compromise circu-
and forearm motion is crucial to aid quency. In such cases, the electric po- gre;
lation. tential generated by various muscles
in prosthetic control motions and to to~
The wrap should be reapplied at
should be determined. A myotester is stre
least every 3 to 4 hours, or more fre- maximize the functional potential of
used for this purpose.
quently if it slips or bunches. The the prosthesis.
Ideally, the therapist and prosthe- elec
elastic bandage should be worn all Pronation and supination of the
tist should work together to identify an
day and night except when bathing. forearm are critical when using a
the best myoelectric sites and to dis- tior
An elastic bandage should never be transradial prosthesis; therefore, sig-
cuss the issues of prosthetic design. tive
worn more than 48 hours before be- nificant attention needs to be paid to
Reliance on a prosthetist with exten- pro
ing replaced with a clean bandage. retaining the motion that still exists
. sive experience in the fabrication of givi
Elastic bandages should be washed between the radius and ulna. Unfor-
upper li mb prostheses is critically im- ove
with mild soap and lukewarm water tunately, forearm range of motion in
portant to guarantee a successful out- van
and thoroughly rinsed with clean wa- the transradial amputee is often ne-
come. aru
ter. glected and, therefore, this range of
The therapist is encouraged to ne11
A preparatory prosthesis might motion is lost in as little as 2 to
communicate openly with the pros-
also be applied early in the shaping 3 weeks. star
thetist on a frequent basis, not only
process. However, a compression ban- con
Muscle Strengthening initially but also when concerns re-
dage is generally preferred because it
garding fit or operation arise. 5 bee
affords better monitoring of skin A therapy program to increase upper sue,
healing and points of pressure. limb muscle strength can be insti- pro
tuted in conjw1ction with the range- Determining the stra
Residual Limb of-motion program. Active resistance Appropriate Type of the
Desensitization can be applied by the therapist, or the
The residual limb is often hypersensi- progressive resistive exercise with cuff Prosthesis um
tive following surgery and requires weights attached to the limb can be The individual who has sustained up- fun
desensitization. This can be carried used. A home program should be per limb loss generally has very little elec
out with gentle massage and tapping provided that contains exercises for knowledge of upper limb prostheses. a pi
techniques. Desensitization can also general strengthening as well as the These persons desperately want and con
be accomplished by vibration, con- specific movements that the amputee need this information, and one goal par
stant touch pressure, or the applica- will perform when using a prosthesis. of the preprosthetic program is to ed- the
tion of various textures to the sensi- ucate the patient regarding prosthe- lose
tive areas of the limb. Maximizing Independence ses. pol
The amputee should be encour- It is critically important to maximize The unique differences between or I
aged to perform these techniques in- functional independence early in the body-powered and electric compo- sis
dependently, for two reasons. First, therapy program. Patterns of depen- nents should be comprehensively de- ing
only the amputee is aware of his or dency can easily occur if the patient is scribed, and examples of each should ins,
her tolerance. Second, the amputee not directed to be independent and be shown and demonstrated if possi- im1
can become more in touch with his or self-reliant. Instruction in change of ble. The question of which upper reh

Chapter 22: Prosthetic Training 277
limb prosthetic device is most appro- A back-up prosthesis is highly rec- tic expectation about the usefulness
priate for a given patient-an all ommended for the upper limb ampu- of the prosthesis as a replacement for
body-powered, aU electric, or a hybrid tee and is especially justified if the the lost body part may be dissatisfied
e (combination of body-powered a nd amputee has demonstrated that the with the ultimate functioning of the
e electric)-is a challenging one. An prosthesis is essential to his or her in- prosthesis and may reject it alto-
objective overview of the advantages dependence. Routine maintenance gether. On the other hand, if the ex-
and disadvantages of body-powered and repairs are necessary with any pectations of the amputee are more
t, and electric components should be prosthesis, and a back-up prosthesis realistic at the beginning of training,
g clearly explained. will be used often. then the ultimate acceptance will be
Advantages of the hook-type, Because of the complexity of man- based on the ability of the prosthesis
a body-powered prosthesis include aging the fitting and training of prox- to improve the amputee's perfor-
d lighter weight, better durability, in- imal bilateral upper limb amputees, mance. It is imperative, then, that the
creased sensory feedback, less ex- referral to a specialized rehabilitation therapist be honest and positive about
pense, and greater ease in seeing the center is strongly suggested. These in- the function of the prosthesis. If the
manipulated object. Advantages of an dividuals require many hours of pro- amputee believes in and understands
r- electric prosthesis include better ap- fessional attention to solve the many the functional potential of the pros-
:e pearance, moderate or no harnessing, fitti ng and training challenges posed thesis, success is more likely.
less body movement to operate, by such amputations. An experienced During the therapist's first en-
)- greater ability to reach overhead and physician, prosthetist, and therapist counter with the amputee, many is-
~s to grasp larger objects, and better grip are critically important if success is to sues need to be discussed and docu-
is strength. 6 be achieved by these individuals. mented if they have not already been
The decision to prescribe an all- A careful inventory of the ampu- dealt with. These issues include the
e- electric prosthesis should be made by tee's lifestyle, support system, educa- etiology and onset of the amputation,
fy an experienced amputee rehabilita-
tional background, and future goals the age of the patient, dominance,
S- tion team. The amputee should be ac- should be taken and discussed. The other medical problems, the patient's
n. tively involved with the discussion of level of independence, the range of
individual with an amputation should
rl- prosthetic options and should be motion of all joints of the residual
be an integral part of the decision-
of given an objective and comprehensive limb, the muscle strength of the re-
making process regarding the pros-
[l- overview of the advantages and disad- maining musculature, the shape and
thesis prescription. Lnvolving the pa-
it- vantages of the primary elbow, fore- skin integrity of the residual limb, the
tient in decisions that affect his or her
arm, wrist, hand, and hook compo- status of the opposite limb, the pres-
own health care helps to restore a
to nents. ence of any phantom pain or residual
sense of control.
,s- It has been my experience that limb pain, previous rehabilitation ex-
uy starting simple a11d providing more Patient Expectations and perience, revisions, and viable muscle
·e- complex devices once the basics have sites for myoelectric control. In addi-
Assessment
been mastered results in significant tion, the therapist should assess the
success for the user of an upper limb During the period of time from cast- patient's knowledge regarding pros-
prosthesis. Once it has been demon- ing until final fitting of the prosthesis, theses, background education and vo-
strated to the rehabilitation team that the amputee may eagerly anticipate cational goals, goals and expectations
the amputee actually wears and uses that the prosthesis will replace, in ap- regarding the prosthesis, and home
the prosthesis and that there are doc- pearance and function , the amputated environment and family support.
umented ways in which the amputee's limb. Unfortw1ately, the finished Although this list of issues may ap-
tp- function could be enhanced by an prosthesis is often a disappointment pear unreasonably long and too
tle electric elbow, forearm, or hand, then for the amputee. It is perceived as ar- lengthy to document, a complete as-
es. a prescription for this more expensive tificial looking, heavy, uncomfortable, sessment is very important. Not only
nd component can be justified. Third- and awkward to operate. If the ampu- will it make a significant difference in
Jal party payers can more easily justify tee is appropriately oriented to the re- the therapist's relationship with the
:d- the required expenditure if this phi- alities of how the prosthesis looks and patient, but the subsequent success of
:i.e- losophy is followed. Unforttmately, operates, he or she will be better pre- therapy will be greatly enhanced if
policies that umealistically limit costs pared to accept its limitations when it this information is gathered before
:en or restrict the patient to one prosthe- is delivered. Therefore, before initiat- therapy begins.
)O- sis per lifetime are becoming increasing a program of upper limb pros- At the first visit to the occupa-
de- ingly common among managed care thetic training, the therapist must ori- tional therapist, the amputee proba-
uld insw·ers, making such staging of care ent the amputee as to what the bly will be carrying the prosthesis in a
ssi- impossible and impeding successful prosthesis realistically can and cannot bag. The therapist should be seJ1Sitive
per rehabilitation. do. An amputee who has an unrealis- to the amputee's feeling of awkward-

Bri
TABLE 1 Sample Prosthesis Wearing Schedule cau
ere
Morning (AM) Afternoon (PM) Evening (PM)
be
Day 1 9:00-9:30 1:00-1 :30 6:00-6:30
ord
Day 2 9:00-10:00 1:00·2:00 6:00-7:00
the
Day 3 9:00-10:30 1:00-2:30 6:00·7:30
iod
Day 4 9:00·1 1:00 1:00·3:00 6:00-8:00
skiJ
Day 5 9:00· 11:30 1:00-3:30 6:00·8:30
Day 6 9:00·12:00 1:00-4:00 6:00-9:00
she
Day 7 All day if no skin problems have occurred
if I
wa1
Figure 2 Donning the prosthesis using
de,
the "coat" method.
introduce the battery-charging proce- of the skin for excess pressure or evi- Th,
dure and the proper use of the battery dence of poor socket fit. This is partic- wa1
ness and reluctance to put on the packs. Instruction man uals are often ularly important if insensate areas and she
prosthesis with others watching. A provided by the manufacturer and adherent scar tissue are present. If red- clo
quiet, nondistracting room with a should be shared at this time as wel l. ness persists for more than 20 minutes Th,
mirror, plus an atmosphere of accep- after the prosthesis has been removed, lo"'
tance and understanding, is helpful. Donning and Doffing the the patient should return to the pros- dri,
Prosthesis thetist for socket modifications. If no be
skin problems are present, wearing pe-
Early Training Body-Powered Prosthesis
riods can be increased in 30-minute sev
Independence in donning and doffing
Dming the first couple of visits, sev- increments three times a day. By the ing
the prosthesis should be established end of 1 week, the upper limb an1putee
eral goals should be addressed. These rati
early by using the "pullover sweater" should be wearing the prosthesis all
include familiarizing the patient with is I
method. The amputee raises his or her day. See Table 1 for an example of a
prosthetic component terminology, dri,
arms overhead as in putting on a pull- wearing schedule.
training the patient to independently soc
over shirt or sweater. As an alternative,
don and doff the prosthesis, orienting mil
the "coat" method may also be used. Care of the Residua l Limb
the patient to a wearing schedule, and tho
The residual limb is put in the socket and Prosthesis
reviewing the care of the residual be
first, and the opposite side follows Following amputation, the skin of the
limb and prosthesis. shr
(Figure 2). Bilateral amputees most of- residual limb is subject to irritation
Prosthetic Component ten use the pullover sweater method. and often to further injury and infec- wit
Terminology tion. Appropriate care of the skin is dar
Myoelectric Prosthesis
therefore a vital part of rehabilitation. use
Body-Powered Prosthesis The prosthesis should be donned and Skin care is covered in detail in chap- if '
Considering that the prosthesis bas doffed with the electronics in the off ter 55. glo
now become the amputee's "arm," it is position to avoid unintended move- The amputee should be encour· pr-c
important that the amputee learn the ments. A residual limb "pull sock" or aged to inspect the skin of the resid- ten
terminology to identify the major "sleeve" may be required for donning ual limb daily. If skin disorders de- ink
components of the prosthesis. Learn- the prosthesis to bring the prosthesis velop, the physician should be called dir
ing the names of the basic compo- in close contact wit h the limb, partic- promptly. A minor disorder can be- obt
nents such as the figure-of-8 harness, ularly for amputees with very short come disabling if it is neglected or wil
cable, elbow unit or elbow hinge, residual limbs. For storage, the pros- treated incorrectly. Adjustment of the Stai
wrist unit, terminal device, and hook thesis should be in the off position, prosthesis is usually necessary, and she
or hand will suffice at this time. and the batteries should be removed. therefore the prosthetist is generally bee
The hand should be fully opened to involved at this time as well. int,
Myoelectric Prosthesis keep the thumb web space stretched. The residual limb should be
Considering that this prosthesis is washed daily, preferably in the lni
now a vital part of the amputee's Wearing Schedule evening, with mild soap and luke- M1
body, it is particularly important to The wearing schedule is extremely im- warm water and then rinsed thor- Be
know the ftmction and names of the portant to review during this first visit. oughly with clean water. Soap left to
A
major parts, such as the electrodes, Initial wearing periods should be no dry on the skin can cause irritation.
tro
battery, glove, and electric hand. The longer than 15 to 30 minutes three After rinsing, the skin should be dried era
initial visit is an appropriate time to tin1es daily, with frequent examination thoroughly using patting motions.

Brisk rubbing should be avoided before the prostJ1esis is actually applied Elbow Flexion and Extension
cause it can irritate the skin. Lotions, and the upper limb amputee practices A critical goal of therapy in patients
creams, and moisturizers should not controlling the prosthesis. These mo- with amputations distal to tJ1e elbow
be applied to the limb unless specific tions are scapular abd uction; chest is to maintain full elbow rau1ge of mo-
orders are given by the physician or expansion; shoulder depression, ex- tion . This range will enable ilie aunptt-
therapist. Strong disinfectants, such as tension, and abduction; humeral flex- tee to reach many areas of tJ1e body
iodine, should never be used on the ion; elbow flexio n and extension; and without undue strain or special mod-
skin of the residual limb. forearm pronation and supination. ifications in the prosthetic design.
The socket of the prosthesis also
should be cleaned often, particularly Scapular Abduction Forearm Pronation and
if the amputee perspfres heavily. In Spreading the shoulder blades either Supination
warm weather, the socket may require alone or in combination with hu- In amputations that retain more than
cleaning at least once or twice daily. meral flexion will provide tension on 50% of the forearm, some degree of
·1- The socket should be washed with the figure-of-8 harness to open the forearm pronation and supination is
c- warm water and mild soap. The inside terminal device. maintained. It is very important to
1d should be thoroughly wiped with a maintain as much of this motion as
d- Chest Expansion
cloth dampened in clean, warm water. possible. This will enable the amputee
es The interior of the socket can be al- This motion should be practiced by to position the terminal device with-
d, lowed to afr dry overnight or can be deeply inhaling, expanding the chest out prepositioning the wrist unit.
,s- dried thoroughly with a towel if it will as much as possible, and then relaxing
10 be used again immediately. slowly. Chest expansion is used in a
·e- If residual limb socks are worn, variety of ways for the amputee with a Training With the
Lte several chan ges may be necessary dur- transhumeral amputation, shoulder Prosthesis Applied
he ing warm weather because of perspi- disartict1lation, or scapulothoracic Introduction to Controlling
·ee amputation. Some prosthetic designs
ration. Washing the sock as soon as it the Prosthesis
all harness this motion witJ1 a cross-chest
is taken off, before the perspiration
.a strap. In some instru1ces of extensive Manual Control of a
dries on it, will prolong the life of the Body-Powered Prosthesis
axillary scarring, the cross-chest strap
sock. The sock should be washed in
may be used in lieu of the figure-of-8 After ilie prosthesis is applied, man-
mild soap and warm water and then
harness. ual contr ols should be reviewed. One
thoroughly rinsed. The sock should
control should be taught at a time
be allowed to dry slowly to avoid Shoulder Depression,
he and then combined with others.
shrinkage. Extension, and Abduction
on
Terminal device positioning In
The prosthesis may be cleaned
~c- This combined movement is used to tJ1e w1ilateral amputee, the terminal
with soap and water, using a soft,
operate the body-powered, internal- device is positioned in the wrist unit
is damp cloth. Rubbing alcohol can be
locking elbow in the prosthesis for the by passive rotation with the opposite
)11. used to clean the inside of the socket
transhumeral amputee. To teach this hand. In the bilateral amputee, the
tp- if an odor develops. Some cosmetic
motion, the therapist should cup one terminal device m ust be pressed
gloves that are used with myoelectric
ur- hand under the residual limb and in- against a stationary object or held be-
prostheses stain easily, so special at- tween the amputee's knees. Bilateral
id- struct the amputee to press down into
tention should be paid to avoiding
ie- tJ1e palm. Th is sinrnlates tl1e motion cable-controlled wrist rotators may
ink, newsprint, mustard, grease, and
led required to lock and unlock tJ1e el- also be prescribed.
dirt. A glove-cleansing cream can be
)e- bow. Elbow joint Rotation at the el-
obtained from the prosthetist that
or bow turntable is manually adjusted or
will remove general soil but not Humeral Flexion
the controlled by leaning the prosthesis
stains. A myoelectric prosthesis
L11d The amputee is instructed to raise the against an object.
should never be immersed in water Shoulder joint The frict ion
1lly residual limb forward to shoulder
because it will seriously damage the
level and to push the residual limb shoulder joint is manually adjusted
internal electronic components. forward, sliding the shottlder blades with the opposite hau1d or by applying
be
the Instruction in Body-Control apart as far as possible. This motion pressure agai11St an object such as the
applies pressure on the cable and alarm of a chair. A locking shoulder
ke- Motions for a
.or- lows the terminal device to open . join t is an option as well.
Body-Powered Prosthesis Scapular abduction and humeral fl ex- Wrist unit If the prosthesis has a
: to
on. A body-powered prosthesis is con- ion are the basic motions to review wrist flexion unit, this can be manu-
·ied trolled by various muscle groups. Sev- with the transradial and more distal ally controlled by applying pressure
,ns. eral motions need to be practiced be- amputee. on the button or, for the bilateral am-

tr:
ar
th
St!
tr:
in
0<
te
fe.
0
Figure 3 The therapist instructs the patient to imitate the desired Figure 4 A form board is used in prosthetic training to practice
muscle contraction in muscle site control t raining. preposit ioning the terminal device. m
C(
er
putee, applying pressure against a sta- racic amputations, tl1e mechanism to pectoralis muscles can be used for n,,
tionary object. lock and unlock the elbow is some- myoelectric control. fe
times a nudge control button attached It is important to note that the
Body Control Motions for a to the thoracic shell. By depressing more proxjmal the level of amputa- qt
Body-Powered Prosthesis this button with the chin, the ampu- tion, the more difficult it becomes for lil
The body-control motions described tee is able to position and lock the el- the prosthetist to fit the individual re
earlier should also be reviewed after bow as desired. (5) The therapist and for the therapist to train that in- Tl
the prosthesis bas been applied and should emphasize that the elbow dividual. a.r
before functional training. It is essen- must first be locked in the proper po- To help the patient understand the e)I
tial that the harness be adjusted prop- sition before the amputee can operate desired muscle contraction, the thera- m
erly before injtiating these exercises. the ternunal device. As described pre- pist instructs the amputee to make Sl
Several ideas are important to re- the desired movement on both sides. pl
viously, biscapular abduction and hu-
member at this point: (1) In aJI high meral flexion (as a combined or sepa- For example, the therapist should ask qi
proxjmal levels of upper limb loss, the transradial amputee to raise the Tl
rate motion) cause the terminal
body-powered elbow flexjon and ex- sound hand at the wrist (wrist exten- m
device to open, and relaxjng allows it
tension are greatly enhanced by a sion) and imagine making that mo- Cl
to close.
forearm lift assist that responds to tion with the phantom hand on the ti
scapular abduction or chest expan- Myoe/eetric Prosthesis affected side (Figure 3 ). Often a ther- tr
sion. Elbow extension is accomplished apist can palpate the wrist flexors and
by gravity if the elbow unit is un-
Locating appropriate muscle sites su-
extensors on tl1e residual limb during c
perficially is the most important as- B
locked. (2) Elbow lock and unlock is tl1is exercise. The amputee should be
pect of the successful operation of a instructed to contract and relax each
one of the most rufficult tasks to learn A
myoelectric prosthesis. The muscle muscle group separately and on com-
in the operation of a prosthesis. The pi
groups selected should approxjmate mand. Electromyography (EMG), in si
patient should be taught "down, back,
normal movements.as much as possi- which the magnitude of the electrical (I
and out" as a reminder to repeat the
ble. The following muscle groups are signals from the muscles is measured,
shoulder depression, extension, and U!
abduction pattern. This pattern not generally used during muscle site se- is particularly useful for tlus step. tr
only locks but also unlocks the elbow lection: Once the maximum response is ti
in an audible two-click cycle. This Transrarual and more distal ampu- found, its location should be marked T
task should be practiced in a quiet, tations: wrist extensors and flexors are on the skin. This process is often done C(
distraction-free room where it is pos- used to open and close the terminal with a prosthetist to select the most ti
sible to hear the clicks without ruffi- device. appropriate muscle site. ai
culty. The motions may need to be ex- Transhumeral amputations: the bi- When measuring surface potentials p,
aggerated at first but soon will be ceps is used for elbow flexion and the with an EMG tester, all the electrodes n
barely observable. (3) Before begin- triceps for elbow extension. The bi- must have good contact with tl1e skin A
ning to operate the terminal device, ceps and triceps can also be used for and must be aligned along the general $(
the amputee should practice locking terminal device opening and closing. direction of the muscle fibers. Moist- h,
and wtlocking the elbow in several Shoulder disarticu.lations and ening the skin slightly with water may C<
positions. (4) In prostheses for shoul- scapulothoracic amputations: the del- improve the EMG signal by lowering b,
der disarticulations and scapulotho- toid, trapezius, latissimus dorsi, or the skin resistance. EMG testing is be- je

.....
....., gun with the most distal portiom of the amputee to maintain an upright tory body motions rather than adjust-
the remnant muscles. posture and to avoid extraneous body ing or prepositioning the hand fost.
The EMG tester can be used to movements. This action is in:lportant to avoid be-
train the m uscles using both visual The five motions basic to hand cause it appears awkward and often
and auditory feedback. The goals at manipulation are reach, grasp, move, becomes a habit. The transhmneral
this poi11t are to increase muscle position, and release. A form board amputee who uses a body-powered or
strength and to isolate muscle con- can be used to train the amputee to electric elbow also should make cer-
tractions. As con fidence and accuracy approach, grasp, and release objects tain the angle of elbow flexion is ap-
improve, the visual or auditory feed- differing in shape, weight, firmness, propriate. A mirror can help the am-
back should be removed. This task and size. Prehension control can be putee see the way ilie body is
teaches the patient to internalize the practiced with a sponge or paper cup. positioned and visualize how the
feeling of each control movement. The amputee is instructed to main- sound arm would have approached a
One advantage of creating this inter- tain constant tension of the terminal particular object or activity. The tl1er-
:ice
nalized awareness of proper m uscle device control cable so as not to apist should remind the amputee to
control is that control and strength- overly squeeze the object being h eld. maintain an upright posture and
ening practice can be continued be- Approach to an object should be such avoid extraneous body movements.
for tween treatment sessions without the that the stationary finger makes in itial Another important aspect of myo-
feedback equipment. contact with the object and the mov- electric training is controlling t he
the The amputee must receive ade- able finger moves to grasp it. Flat ob- gripping force of the terminal device.
lta- quate training and practice in mitiat- jects can be moved to the edge of a The amputee learns this by visually
for ing these muscle contractions before surface such as a table and then observing the degree of m uscle con-
ual receiving the myoelectric prosthesis. grasped with the terminal device in a traction that produces a specific result
111- This will help minimize the anxiety horizontal position . Grasp is generally in the myoelectric hand. Styrofoam
and frustration the individual often controlled by rubber bands on the packing peanuts work well for devel-
the experiences while learning to use a term inal device, which can be added oping this skill. The amputee m ust
:ra- myoelectric prosthesis. The amputee's as tolerated. Springs may be used as learn how to pick up the peanut with -
.ake success and effectiveness in using th e an alternative. out crushing it. Good grasp control
:Jes. prosthesis is closely related to the Controls training for the bilateral ilirough training with materials such
ask quality of the preprosthetic training. upper limb amputee may require an as Styrofoam, cotton balls, or sponges
the The therapist also needs to recognize e:>..1:ended period of time to perfect. helps develop the control needed to
:en- muscle fatigue, which frequently oc- Learning to control the motion of n.vo handle paper cu ps, eggs, potato chips,
no- curs during this process, allowing prostheses separately is a complex and sandwiches and even to hold an-
the time for muscles to relax d uring the motor process. Passin g an object such other person's hand. Release is ac-
1er- treatment session. as a ruler back and forth from one complished by visualizing a wrist ex-
and terminal device to the other may help tension contraction, or envisioning
ring Controls Practice in reinforcing this pattern. the phantom hand up or open. This
I be Body-Powered Prosthesis response should become quite auto-
:ach A form board is frequently used to Myoelectric Prosthesis matic if good preprosthetic training
om- practice prepositioning as well as !ten- Sin:lple approach, grasp, and release of the muscles has occurred.
, in sion control of the terminal device activities are often practiced with a Eventually the performance of spe-
deal (Figure 4). Prepositioning involves form board on which objects of vari- cific movements will take less cogni-
red, using both manual and active con- ous shapes, sizes, and firm ness are tive effort, and tl1e movements be-
;tep. trols to place the prosthesis in the op- displayed. The amputee should first come automatic. Functional use
: is timal position for a specific activity. visualize how tl1e object should be ap- training can then be introduced into
rked The therapist should be alert for any proached and grasped, and then pre- the therapy program.
lone compensatory body motions ilie pa- position the myoelectric hand. For
nost tient might make when approaching example, in approaching a glass or Functional Use Training
an object. Often the amputee will re- cup, the hand should face in, toward Functional use trainmg is ilie most
1tials position the entire body rather than the midline, to grasp the glass as a difficult and prolonged stage of the
odes reposition the elbow and wrist units. normal hand would. The fingers of prosthetic training process. The suc-
skin A mirror can assist the amputee in the hand should not be positioned cess or failure of the amputee's accep-
1eral seeing the position of the body. It is downward, because a normal hand tance and use of the prosiliesis de-
oist- helpful to instruct the amputee to does not approach a glass in this posi- pends on (1) the motivation of the
may consider how ilie arm would bave tion. patient, (2) the comprehensiveness
:ring been positioned to approach ilie ob- As with a body-powered prosthe- and quality of the tasks and activities
s be- ject. It is often necessary to rem ind sis, often the patient uses compensa- practiced, and (3) of critic.al impor-

the unilateral amputee within 1 to

TABLE 2 Roles of Body-Powered Hand and Opposite Hand in Bilateral 2 months of the amputation when- siti,
Activities of Da ily Living As
ever possible. These individuals defi-
Activity Body-Powered Hand Opposite Hand nitely show a greater propensity for the
Cutting food Holds fork Holds knife to cut wearing and successfully using their siti·
Using scissors Holds material to be cut Uses scissors prostheses. This applies to all ampu-
Dressi ng activities Holds fabric such as waistband Tucks in shirt, fastens snap or tees, whether fitted with body- gui
button (button hook may be powered or electric components. Bi- am
used)
lateral skills will be encouraged, self- ual
Opening jar or Grasps middle of contai ner with Unscrews lid or cap
maximum grasp
image is often enhanced, and
bottle
Washing dishes Manipulates washclot h or Holds dish
functional independence is frequently Ve
sponge (avoiding submerging restored. A<
device) Training should address activities
Dii
Drying dishes Manipulates towel Holds dish of daily living that are useful and pur-
Uses hammer or wrench
pee
Using tools Holds nail or bolt in hook poseful. Activities such as cutting
fingers irn
food, using scissors, getting d ressed,
Driving Assists opposite arm Turns steering wheel are
opening a jar or bottle, washing
on!
dishes, hammeri11g a nail and using
other tools, and driving a car should
bil
be practiced so that the amputee will she
COl
tance, the experience and enthusiasm and to hold and stabilize objects while automatically use the prosthesis when
of the occupational therapist. The the opposite hand performs fine mo- encountering the sam e activity in to
training experience is most effective if tor prehension activities. T he pros- daily life. abi
tl1esis should be expected to assume T be therapist should review a list tUI
the same therapist remains with the
amputee tlu-oughout the entire pro- no more than 30% of the to tal hmc- of bilateral activities of daily living inj
tion of the task in bilateral upper with the amputee to determine which an,
cess.
tasks are the most important for that Wli
It is extremely important to em- limb activities, with the opposite arm
phasize to the unilateral amputee that and hand always dominant. individual. These are the activities to to
the prosthesis will usually play a non- The amputee who has lost an arm focus on, stressing throughout the ac- ste
dominant role, supplementing the or hand will quickly develop tech- tivity that the prosthesis is used to as- fo,
function of the opposite hand. The niques to accomplish tasks unilater- sist the opposite hand. The bilateral do
prosthetic terminal device is most ally, and these habits will be difficult activities listed in Tables 2 and 3 are W(
useful for gross prehension activities to break. It is therefore essential to fit good examples to review and practice. an
Table 2 describes how activities would tio
be accomplished using a body- th,
powered prosthesis. Table 3 lists simi- th,
TABLE 3 Roles of Myoelectric Hand and Opposite Hand in Bilateral Activities of
Dai ly Living lar activities as they would be per- m,
formed using a myoelectric hand.
Activity Myoelectric Hand Opposite Hand Several activities are also shown in a1rc
Opening a jar Holds the jar Turns the lid Figure 5. ti.r
Tying shoelaces Holds one shoelace to Performs the tying With practice, these activities and gr,
stabilize
many others improve and ultimately ps
Using knife and fork Holds fork to stabilize Holds knife to cut
become automatic. It is extremely im-
Holding a tray Picks up and releases item Holds tray
portant to reinforce and emphasize H
Opening a tube of Holds t he tube Turns the cap
toothpaste
tl1e fact that activities involving water, At
including bathing and grooming ac-
Stirring substance in a Holds bowl with a strong Holds mixing spoon/fork ln
bowl grip tivities, must be done without a myo-
SC
Cutting fru it or Holds the fruit or vegetable Holds t he knife to cut electric hand because of tl1e damag-
be
vegetables f irm ly ing effects of water on the electric
fa
Using scissors to cut paper Holds the paper 1to be cut Uses scissors norma lly motor and battery. The therapist
sh
Zipping a jacket from the Holds the anchor tab Manipulates the pull tab at should also advise myoelectric hand
bottom up t he base and pulls upward Wt
users against subjecting tl1e myoelec-
Buckling a belt Holds buckle end of belt to Manipulates the long end of m
tric component to excessive vibration,
stabilize it the belt into t he buckle b~
sand, dirt, or the extremes of h eat and
Donning socks Holds one side of sock Holds other side of sock and C(
pulls upward cold. These too can seriously impair
p1
the electronic components.

:o The importance of correct prepo-

l- sitioning cannot be overemphasized.
1- As a rule, most difficulties in pros-
>r thetic use are a result of improper po-
ir sitioning.
1- A valuable and comprehensive
v- guide to the specifics of training the
,J - amputee is found in the classic Man-
f- ual of Upper Extremity Prosthetics.7
td
ly Vocational and Leisure
Activities
es Discussing vocational needs and ex-
.r -
pectations with the amputee is very
1g important. Unfortunately, this is an
d,
area that is often overlooked or given
rig
only brief attention during the reha-
[lg
bilitation process. This discussion
Lld
should occur later in the training
·ill
en continuum, when the amputee begins
in to acknowledge and accept the dis-
ability. Although not everyone can re-
ist turn to the exact job held prior to the
ng injury, a review of job responsibiliities
Figure 5 Activities of da ily living performed with a myoelectric ha nd. A, To open a jar,
ch and expectations can be explored the myoelectric hand holds the jar and the sound hand turns t he lid. B, When tying
mt with the therapist. It may be possible shoelaces, the myoelectric hand stabilizes and holds, ,whi le t he opposit e hand maneu-
to to break down the tasks of a job into vers the laces. C, The myoe lectric hand holds the fork to stabilize t he food whi le t he op-
posite ha nd holds the knife. D, The sound hand is used to hold a tray, and the myoelec-
3(- steps that can be practiced and rein-
t ric hand can grasp and release items.
as- forced in therapy. If the therapist can
ral do an on-the-job site evaluation, it
are would be a valuable addition to the Summary bilitation program, however, is the
.c e. amputee's comprehensive rehabilita- motivation and the desire of the per-
Jld tion . If changes and adjustments to The rehabilitation of a person with son with an amputation to become
ly- upper limb loss can be both challeng- independent. This pivotal ingredient
the work environment are necessary,
ing and rewarding. Especially in in- should be cultivated and reinforced
111- the therapist could advise in these
,er- stances of higher level and bilateral by the members of the rehabilitation
modifications.
[ld. amputations, significant training and team. The impact the treatment team
Recreational and leisure act1V1t1es
in expertise on the part of the rehabilita- makes during this inlportant process
are also important to discuss at this
tion team is essential. will remain with the patien t for life.
time. These actJv1t1es contr ibute
u1d The potential of the person with
greatly to an individual's physical and
tely an amputation is limitless. Amputees
psychological well-being. have been able to accomplish activi-
Lm.-
ties that never would have been ex-
References
)ize Home Instructions
pected. The success of a rehabilitation 1. Bennett JB, Alexander CB: Amputa-
ter,
At the conclusion of training, home tion levels and surgical tech n iques, in
ac- effort does not rest solely on the qual-
instructions that include a wearing Atkins DJ, Meier RH III (eds): Com-
.yo- ity of training to use a prosthesis but
schedule and prostlieses care should prehensive Management of the Upper-
,ag- is closely intertwined with the quality Limb Amputee. New York, NY,
be reviewed with the patient and the of the medical management, the qual-
tric Springer-Verlag, 1989, pp 1-10.
fam iJy. A follow-up appointment ity and fit. of the prostliesis, func-
pist 2. Atkins DJ: Postoperative and pre-
should also be made at this time, as tional t raining, and conscientious
and prosthetic therapy programs, in Atkins
lec- well as a list of the rehabilitation team follow-up with the amputee once the DJ, Meier RH IU (eds): Comprehensive
ion, members and their telephone num- rehabilitation phase is complete. Management of the Upper-Limb Ampu-
and bers, which will enable the patient to Follow-up is critically important and tee. New York, NY, Springer-Verlag,
pair contact the appropriate person when is often overlooked. Perhaps the most 1989, pp 11-15.
problems arise.8 important aspect of a successful reha-

3. Meier RH III: Amputations and pros- III (eds): Comprehensive Management Angeles, CA, Universi ty of California
thet ic fitting, in Fisher SV, Helm PA of the Upper-Limb Amputee. New York, at Los Angeles, 1958.
(eds): Comprehensive Rehabilitation of NY, Springer-Verlag, 1989, pp 39-59. 8. Atkins D: Adult upper limb prosthetic
Burns. Baltimore, MD, Williams & 6. Atkins D: Managing self-care in adults training, in Bowker JH, Michael JW
W ilkins, 1984, pp 267-310. with upper extremity amputations, in (eds): Atlas of Limb Prosthetics: Surgi-
4. Malone JM, Fleming LL, Robertson J, Christiansen C (ed) : Ways of Living: cal, Prosthetic, and Rehabilitation Prin-
et al: Immediate, early, and late post- Self-Care Strategies for Special Needs, ed ciples, ed 2. Rosemont, IL, American
surgicaJ management of upper-limb 2. Bethesda, MD, American Occupa- Academy of Orthopaedic Surgeons,
amp utation. J Rehabil Res Dev 1984;2 I: tional Therapy Association, 2000, 2002, pp 277-29 1. (Originally pub-
33-41. pp 221-230. lished by Mosby-Year Book, 1992.)
5. Atkins DJ: Adult upper-Limb pros- 7. Santschi W, Winston M (eds): Manual
thetic training, in Atkins DJ, Meier RH of Upper Extremity Prosthetics, ed 2. Los
Sl
C.
jt
tJ
lb
tJ
a
r:
v
h
ii
tl
c
a
d
f,
le
(
JP
i:
a
s
c
r
c
c
i
}
(
~

LC Brachial Plexus Injuries: Surgical
and Prosthetic Management
Allen T. Bishop, MD
Introduction
Injuries to the brachial plexus ca11 re- the plexus. Based on more than 18 avulsion of the nerve root has oc-
sult from a variety of etiologies, in- years of experience with more than curred proximal to the spinal root
cluding birth injuries, penetrating in- 1,000 patients with plexus injuries, ganglion; there is complete motor and
JUnes, falls, and motor vehicle Narakas estimated that 70% of trau- sensory loss in the involved root and
trauma. Closed injuries produce most matic brachia] plexus injuries are sec- denervation of the deep paraspinal
brachia] plexus injuries and are often ondary to motor vehicle accidents. muscles of the neck (Figure 1). Sev-
the result of traction, compression, or Approximately 70% of these motor eral specific clinical findings are
a combination of both. Traction inju- vehicle accidents involve either mo- pathognomonic for nerve root avul-
ries occur when the head a11d neck are torcycles or bicycles. Of the cycle rid- sions associated with brachia! plexus
violently moved away from the ipsi- ers, 70% have multiple injuries. Over- injuries: (1 ) Rhomboid paralysis indi-
lateral shoulder, often resulting in an all, 70% of patients with brachial cates a CS nerve root avulsion;
injury to the CS-C6 nerve roots, or plexus injuries have supraclavicular (2) serratus anterior paralysis is con-
the upper trunk. Traction to the bra- lesions, and of those with supraclavic- sistent with avulsion of CS through
chia! plexus can result from a violent ttla r lesions, 70% have at least one C7 nerve roots, and (3) Homer's syn-
arm movement. When the arm is ab- root avulsed. Of patients who have a d rome (ptosis, miosis, and anhidro-
ducted over the head with significant root avulsion, at least 70% have avul- sis) is pathognomonic for C8-Tl
force, traction wiU occur within the sions of the lower roots (C7, C8, or avulsions (Figure 2). Postganglionic
lower elements of the brachia] plexus Tl). Finally, of patients with a lower injuries occur distal to the spinal gan-
(C8-Tl roots or lower trunk). Com- root avulsion, nearly 70% will experi- glia and have a more favorable prog-
pression injuries to the brachia} ence persistent pain. nosis than preganglionic injuries,
plexus can occur between the clavicle both in terms of spontaneous recov-
a11d the first rib; these injuries may be Clinical Evaluation
ery and outcomes of surgical recon-
secondary to expanding hematomas Evaluation of brachial plexus injur-
struction.
or malignancies. ies often occurs after acute
Although it is difficult to ascertai n life-threatening injuries are treated. A History of Treating Brachia!
the number of brachia] plexus inju- thorough physical examination is Plexus Injuries
ries that occur annually, the incidence necessary to determine if the lesion is
continues to increase with the advent ( 1) preganglionic, in which the root is Treatment recommendations for
of more extreme sporting activities, avulsed directly from the spinaJ cord complete root avulsions have varied
more powerful motor sports, and the proximal to the dorsal root ganglion, widely over the past 50 yeru·s, and
increasing number of survivors of or (2) postganglionic, in wh ich the outcomes have ranged from fair to
high-speed motor vehicle accidents root is avulsed or otherwise injured dismal. Just after World War II, the
(attributed to the use of airbags). 1-9 distal to the dorsal root ganglion standard approach was surgical re-
Most patients with these injuries are within the trunk, divisions, cords, or construction consisting of shoulder
males between 15 and 25 years of terminal branches. The differences fusion, elbow bone block, and finger
age. 1•8 •10•11 Narakas 12 proposed the between these lesions have significant tenodesis. 13 In the 1960s, trans-
"law of seven 70s" to describe the prognostic and therapeutic implica- humeral amputation combined with
types and mechanisms of injury to tions. With a preganglionic injury, shoulder fusion in slight abduction
American Academy of Ortlwpaedic Surgeons 285

286 Section II: T he Upper Limb
shoulder abduction, hand sensibility,

wrist extension and finger flexion,
and intrinsic function of the hand.
Timing of reconstruction or inter-
vention depends on the mechanism of
injury and the type of injury. Immedi-
ate exploration and primary repair of
the injured portion of the brachia!
plexus are indicated for sharp, open
injuries. If the open injury occurred
secondary to impact from a blunt ob-
ject, the ends of the lacerated nerve A
should be tagged and addressed 3 to
Fig1
4 weeks later to excise the zone of
pat
nerve injury and place an interposi-
tion nerve graft. Patients with gunshot
wounds should be observed because
most of these injuries are neurapraxic.
Early exploration and reconstruction
Figure 1 Horizontal cross section of a typical cervical vertebra showing the anatomy of (between 3 and 6 weeks after injury) is
t he intervertebral foramen. 1, Anterior spinal root. 2, Posterior spinal root with dorsal indicated in patients with gunshot
root ganglion. 3, Spinal nerve. 4, Transverse process. 5, Articular facet. 6, Posterior
wounds when there is a high suspicion
branch of spinal nerve. 7, Anterior branch of spinal nerve (plexus root). 8, Posterior
transversarius muscle. 9, Anterior transversarius muscle. 10, Anterior scalenus muscle. of root avulsion. Routine exploration
11, M iddle scalenus muscle. 12, Posterior scalenus muscle. 13, Vertebral pedicle. 14, Pos- (between 3 and 6 months after injury)
terior tubercle of transverse process. 15, Anterior tubercle of transverse process. Pregan· is typically performed in patients who
glionic injuries occur proximal to 2, the dor·sal root ganglion. Injuries distal to this are have partial injuries and partial paral-
considered postganglionic. (Adapted with permission from Herzberg G, Narakas A,
ysis in which there is a suspicion of
Comtet 11: Surgical approach of the brachia/ plexus roots, in A/not JY, Narakas A (eds):
Traumatic Brachia! Plexus Injuries. Paris, France, Expansion Scientifique, 1996, pp 19-22.) root avulsion. Delayed exploration oc-
curs 6 months after the injury, whereas
late ex-ploration occurs after 12
and flexion was advocated. 14 The the pathophysiology of nerve injury months. Delayed or late surgery often Fig
classic article of Yeoman and Sed- and repair, as well as the recent ad- avl
precludes successful direct repair or
don 15 noted the tendency for patients me
vances in microsurgical techniques, neurotization because nerve regenera-
to become "one-handed" within 2 has allowed reliable restoration of el- tion to the target muscles requires
years of injury, a clinical outcome bow flexion and can provide useful
deemed unsatisfactory. They reported
more time than the motor end plate Tt
primitive prehension of the hand. can survive after denervation.
the lack of good results from the Current advances in brachia] plexus Ideally, electrodiagnostic evalua- Su
primitive surgical reconstruction of reconstruction, especially the mi- tion should be performed by 3 to inj
that era; however, outcomes were pre- crovascular reconst1·uctive proce- 4 weeks after injury, followed by CT rie
dominantly good or fair when ampu- dures, as well as the prosthetic/ myelography to evaluate the status of in1
tation with shoulder fusion was per- orthotic advances, are the focus of the cervical roots. The role of MRI in do
formed within 24 months of injury. this chapter. this context continues to evolve; cur- fu:
The authors also noted that the loss rently, it is considered best for visual- tn
of glenohumeral motion caused by izing the dorsal and ventral rootlets de
injury to the suprascapular and axil- Current Concepts of but has been less accurate than CT u:r.
lary nerves limited the effectiveness of Surgical myelography in identifying root fo
body-powered devices and that man- avulsion. 16 · LS We prefer CT myelogra- tic
ual laborers seemed to accept hook
Management in.
phy because it appears to be the most
prostheses much more readily than The two most important co)lcepts in sensitive and specific test to identify ga
did office workers with similar inju- the surgical management of brachia! root avulsion injuries (Figure 3). 6
ries. Although these observations re- plexus injuries are (1) the priority of Consultation with a pain manage- fu
main valid today, recent advances in restoring upper arm function, and ment team and a physical therapist fu
brachia! plexus reconstruction have (2) the implications and timing of for tl1e hand should be initiated as a1
produced clinical outcomes superior surgical reconstruction. The highest soon as possible after the injmy to ad- d~
to those reviewed by Yeoman and priority in restoring the flail extrem- dress the severe nemitic pain and to di
Seddon. A better understanding of ity is elbow flexion, followed by prevent joint contractures. 12' 15 ' 19 - 28 pc

Chapter 23: Brachial Plexus Injuries: Surgical and Prosthetic Management 287
f
1
1
i
e A
0
Figure 2 A, Scapular winging is indicative of CS through C7 root avulsions. B, Homer's syndrome (ptosis, miosis, and anhidrosis) is
1f pathognomonic for a C8-T1 avulsion injury. (Reproduced from the Mayo Foundation, Rochester, MN.)
I-
)t
;e
c.
n
is
)t
,n
m
y)
10
J-
of
c-
as
12
en Figure 3 Myelography remains the most sensitive and specific method of detecting root
avulsions. A, The formation of pseudomeningomyeloceles at CS and T1 are pathogno-
or monic for root avulsions. B, CT myelography further delineates the injury.
·a-
:es Figure 4 Fibrin glue can simplify the ap-
present for less than 6 months. With a proximation of multiple strands of nerve
1te Treatment graft by creating a single large nerve
free-functioning muscle transfer, a stump when several graft strands are
1a- Surgical treatment of brachia! plexus muscle and its neurovascular pedicle glued together. The graft ends are fresh-
to injuries falls into several broad catego- are transplanted to a new location and ened, and the mass is then coapted to
:T ries, including primary nerve repair, the motor nerve is neurotized with a the recipient nerve with several epineu-
of interposition nerve cable grafting, ten- rium sutures. (Reproduced with permis-
functioning motor nerve. Free- sion from Hentz VR: Microneural recon-
in don transfers, neurotization, and free-
functioning muscle transfers are indi- struction of the brachia/ plexus, in Green
ur- functioning muscle transfers. Tendon DP, Hotchkiss RN (eds): Green's Hand Sur-
cated in delayed (3 to 6 months after
1al- transfers should be delayed until evi- gery. Philadelphia, PA, Churchill Living-
injury) or late (more than 12 months
lets dence shows that further recovery is stone, 1993, pp 1223-1252. //lustration by
unlikely. Primary repair is indicated after injury) presentations. Elizabeth Roselius,© 1993.)
CT
oot for patients with acute, sharp lacera-
:rations. Interposition nerve cable graft- Nerve Grafts nerves be used. These nerve segments
1ost ing is indicated for those with post-
Sources of donor nerve grafts include may be cabled together with fibriJ1
tify ganglionic injuries that aJ"e less than
the sural nerves, ipsilateral cutaneous glue and then ·sewn in place (Figure 4).
3). 6 months old. With neurotization,
nerves, lateral cutaneous nerves of the In patients with complete avulsions,
1ge- function is restored by transfer of a
thigh, saphenous nerve, and the ulnar the ulnar nerve can be harvested as a
pist funct ional but less important nerve to
nerve (if C8 and Tl are avulsed). The vascularized nerve graft based on the
I as a nonfunctioning but more important
denervated nerve. Neurotization is in- size mismatch between the plexus and superior collateral ulnar artery and
ad-
dicated for patients with either pre- or the individual nerve often requires then effectively used as a free vascuJar-
l to
:s postganglionic lesions that have been that multiple strands of bundled ized interposition nerve graft from

neurotization sources to the median

nerve (Figure 5).
Neurotization
Intercostal nerves can be harvested
from the third, fourth, fifth, and sixth 1Sto
ribs and effectively used to provide 20cm
motor nerves to targeted muscles
or sensation to injured sensory
nerves. 15 •29 -36 Each intercostal nerve
has a motor and sensory branch and
-:/ 20to
25cm
can be easily harvested and neuro-
tized to the target nerves (Figure 6). Fi!
Each intercostal nerve contains about in
(A
1,300 myelinated axons. Thus, two or
three intercostal nerves are typically
use_d together. Occasionally, the inter- fa
Figure 5 A, The ulnar nerve can be used as a vascularized nerve graft at the level of t he
costaJ nerves require elongation with arm (vascularized by the ulnar medial inferior pedicle) or at the forearm (vascularized pl
a nerve graft because the distance to by the ulnar artery). (Reproduced with permission from Lebreten E, Oberline CH, A/not is
reach the target nerve or muscle is too JY: The ulnar nerve at the arm and forearm, in A/not JY, Narakas A (eds): Traumatic Bra-
Sll
long. The greatest disadvantage to us- chia! Plexus Inj uries. Paris, France, Expansion Scientifique, 1996, pp 28-32.) B, A clinical
example of a vascularized ulnar nerve graft coapting the contralateral C7 root to the
ing a nerve graft is that two lines of
median nerve.
coaptation need to be crossed by re-
SC
generating nerve fibers. The advan-
l!
tage of using a nerve graft is that the in:,
intercostal nerves can be transected
Ill
more proximally, where the nwnber
at
of motor fibers is greater.
jll
The spiJJal accessory nerve (cranial
[€
nerve XI) can also be used as a donor
B
nerve. 2 •7•8 •29 •32· 13 The terminal branch
of the spinal accessory nerve can be
re
easily harvested and has about 1,700 Figure 6 A, lntercostal nerves can be isolated from the inferior portion of the ribs and g1
myelinated axons. Thus, the spinal ac- harvested from the costochondral margin to t he midaxillary line. B, Each intercostal tl
cessory nerve is an excellent donor nerve contains sensory and motor components that can be easily identified with a nerve tc
stimulator and separated for neurotization into muscles and sensory nerves. e1
nerve for the suprascapular or axillary
nerve to restore shoulder stability or b
to neurotize a free-functioning mus- ri
Accessory
cle transfer (Figu1·e 7). nerve tJ
The ipsilateral phrenic nerve can (]
be used; however, before its use, dia- n
phragmatic and pulmonary function Motor branches tl
must be assessed.29 ' 34' 35 Hemidia- JU
phragmatic paralysis is an absolute Retrostylok:J tt<

contraindication for phrenic neuroti- triangle -+---:.4 t(
zation. Patients with severe chest inti
Terminal
jury or multiple fractured ribs require trunk lJ
careful evaluation of pulmonary fc

function because ha1·vest of the ipsi- s:
lateral phrenic nerve can further jeop-
ardize pulmonary function. Simulta-
A "'3
neous harvesting of intercostal and
Figure 7 A, The spinal accessory nerve (cranial nerve XI) is a pure motor nerve that can
phrenic nerves restricts pulmonary provide about 1,700 myelinated fibers. B, The fi rst and second motor branches are typ-
s
function in the early postoperative ically preserved, and t he terminal branch is used for plexus neurotization. (Reproduced t:
period. 44 Harvest of the phTenic nerve with permission from A/not JY, Overline CH: Nerves available for neurotization, in A/not v
is also contraindicated in young in- JY, Narakas A (eds): Traumatic Brachia! Plexus Inj uries. Paris, France, Expansion Scienti- T
fique, 1996, pp 31 -38.)

Chapter 23: Brachia! Plexus Injuries: Surgical and Prosthetic Management 289
Figure 9 Transferring a portion of an ip·

silateral functioning ulnar nerve to the
Figure 8 The contralateral C7 root can be harvested with little or no functional deficit musculocutaneous nerve to provide bi·
in the donor arm. We prefer to use the anterior half of the C7 root (white vessel loop) ceps function. Several fascicles of the ul-
(A) and use a vascularized ulnar nerve graft as the conduit to the median nerve (B). nar motor nerves are identified and
transferred to the musculocutaneous
nerve. The ulnar nerve is identified by the
fants and in patients with any dia- function (ie, patients with upper vessel loop, and the ulnar nerve to the
the
zed phragm paralysis. The phrenic nerve trunk injuries or C5-C6 avulsions), musculocutaneous nerve is neurotized by
'n ot is best suited for neurotization of the several fascicles of the ulnar motor these fascicles.
3ra- suprascapular nerve. nerves can be transferred to the bi-
1ical ceps motor branch of the musculocu-
Uninjured contralateral C7 root brachia! plexus limits the options for
the
used as donor nerve was first de- taneous nerve at the midhumeral surgical reconstruction.
45 level without significant loss of distal
scribed by Gu and associates in Free-functioning muscle transfer
1992, and by Chuang and associates46 motor or sensory function to the involves moving a muscle and its mo-
in 1993. This procedure, however, re- muscles of the hand that are mediated tor nerve to a donor site. The munber
mains controversial. Based on avail- by the ulnar nerve (Figure 9). This of available extraplexal donor nerves
able reports, transection of the unin- transfer is possible because individual is limited, and the timing of recon-
jured contralateral C7 root does not ulnar nerve fascicles are mixed at this structive procedures is critical. De-
result in significant loss of function . level, consisting of extrinsic and in- spite favorable reports of early nerve
By elongating the contralateral C7 trinsic motor fibers as well as sensory grafting and transfer techniques, at-
root with a vascularized ulnar nerve fibers. The results are excellent, and tempts to restore function to long-
graft to the ipsilateral med ian nerve, donor site morbidity is very low. standing denervated muscle are usu-
and
)Stal the contralateral C7 root can be used Other sources for donor nerves for ally unsuccessful. 30'54'56'57 This lack of
erve to neurotize the median nerve or lat- neurotization include the cervical success has resulted in free-
eral cord. Reduced morbidity has plexus, the long thoracic nerve, the functioning muscle transfers to be
been reported when the anterosupe- hypoglossal nerve, and nerve root used in conjUJ1ction with extraplexal
rior portion of C7 is used rather than stumps of postganglionic avulsions at motor nerve transfer to restore func-
47 the root-trunk level. tion for patients with brachia! plexus
the entire contralateral C7 root
(Figure 8). Donor site morbidity is avulsions or when the time from in-
Free-functioning Muscle jury to surgery is longer than 6
minimal, initially" resulting in pares-
thesia in the digits affected by the C7 Transfer months to 1 year. 8 •41 ·58.62 Free-
ezius nerve root and mild weakness of pec- Advances in microsurgical techniques functioning muscle transfers provide
;le toralis, triceps, and/or wrist ex- have led to innovations in surgical re- reliable elbow flexion when a delay in
tension.46"48 The functional loss is construction of the upper extremity treatment prevents direct graft or bi-
typically limited to reduced sensibility following brachiaJ plexus injury. ceps neurotization and pr0>..im.al
in the index finger and some reduced Reinnervation of the biceps and muscle strength is insufficient to al-
force of the triceps and finger exten - shoulder musculature using a combi- low tendon transfers. 8 ' 42 '52'58'59'63
sion. Both the paresthesia and motor nation of nerve grafting and neuroti- With this procedure, circulation in
weakness diminish during a period of zation techniques has resulted in reli- the transferred muscle is restored
3 to 6 months. able restoration of elbow tlexion and with microsurgical technique, vessels
Oberlin and associates 49•50 de- shoulder abduction when surgical are anastomosed, and the motor
t can
scribed the use of portions of a func- intervention occurs within 6 to nerve is neurotized with one of the
'typ-
1uced tioning ipsilateral nerve. In patients 9 months of injury.29,30,33,36,46,s1-s1 In nerves described above. Within sev-
~/not with loss of the musculocutaneous many instances, however, delay in eral months, the transferred muscle
ienti- n erve, but with preserved ulnar nerve treatment or complete avulsion of the becomes innervated and is reinner-

nal accessory nerve or intercostal sig

nerves. Shoulder fusion can be pur- on
sued later if the shoulder becomes SOl
problematic. Sill
VO.
CS through Cl
Injuries involving the CS through C7 Cc
nerve roots add radial palsy to the T}
clinical picture presented above. Not th,
only does the sensory loss in the hand
is
increase but all active extension at the
bu
wrist, hand, and fo1gers is lost as well.
Neurotization of the posterior cord
pr
ch
can be helpful to restore wrist exten-
sion; however, restoring elbow flexion de
Figure 10 A, If more than 6 months have passed since the time of injury, the fibrotic lo:
and denervated biceps is replaced with a free-funct ioning gracilis muscle that is neuro- and shoulder function remains the
tr<
tized by the intercostal nerves. (Reproduced from the Mayo Foundation, Rochester, priority. If there are not enough do-
MN.) B, This approach can predictably restore elbow function. W<
nor nerves to neurotize the posterior
cord, either a static or spring-assisted pl
wrist, hand, and finger extension can a
be added to the previous orthosis.27 co
vated by the donor nerve. Eventually, ganglionic injury. 19 Nonetheless, it is pr
the transferred muscle functions in- instructive to describe the treatment C8-T1 m
dependently. A variety of muscles and options by pattern of injury. Injuries involving the CS-Tl nerve tr:
nerves can be transferred, including roots are generally associated with tr
the latissimus dorsi with the thora- Preganglionic Injuries good shoulder and elbow function m
codorsal nerve, the rectus femoris CS- C6 but loss of finger flexor, extensor, and tb
with the femoral nerve, and the graci- intrinsic fu nction. Surgical explora- g,
In the C5-C6 preganglionic lesion, m
lis with the anterior division of the tion of the plexus at this level is often
there is loss of elbow flexion as well as
obturator nerve. The gracilis has be- futile because the nerve roots are of-
shoulder abduction. The main goal of ((
come one of the most commonly ten so avulsed that they cannot be re-
treatment is to restore elbow flexion SL
used muscles in brachia} plexus repaired. Treatment of injuries at this
and provide shoulder stability and ab- fc
construction because of (1) its level remains controversial because
duction. Several treatment options
proximally based muscle neurovascu-
lar pedicle, which allows earlier rein-
can be pursued in injuries less than
6 months old. One option is neuroti-
restoration of intrinsic function of
the hand remains untenable. In these "'
n
e1
nervation, and (2) its length, which situations, the great distance and time
zation of the musculocutaneous mo- the nerve has to regenerate to reach SI
can extend into the forearm for hand
tor branch and suprascapular nerve the intrinsic muscles appears to ex- li
reanimation . The gracilis can be used
with intercostal nerves (typically two ceed the survivability of the motor al
to restore biceps function, especially if
to three nerves) and the terminal end plates. Howevet? intercostal neu- n
there is a delay in treatment 39•40
branch of the spinal accessory nerve rotization to the ulnar nerve has been n
(Figure IO) , or as a double-muscle
(cranial nerve XI), respectively. Use of reported to achieve grade Ill motor a
transfer in the novel and revolution-
the sensory portion of the intercostal recovery. 31 11
ary Doi procedure to restore elbow
nerves with neurotjzation to lateral Surgical reconstruction by tendon a
flexion, wrist extension, and finger
cord contribution to the median transfers is often especially successful tc
flexion in the acute setting.7 •8 •64
nerve can provide sensation to the in these patients and can restore sig- g
hand. Another option is to perform nificant function . Patients who sus- p
an Oberlin transfer of motor fascicles tain a concomitant traumatic trans- s,
Treatment Based on of the ulnar nerve to the motor radial amputation should be able to b
Level of Injury branch of the musculocutaneous operate a body-powered or switch- t:
nerve and the spinal accessory nerve controlled terminal device. Loss of t
Pure injuries to the brachia! plexus as to the suprascapular nerve. In the late forearm innervation eliminates myo- :r.
described below rarely occur. More or delayed presentation (more than electric control sites below the elbow. r
commonly, injury occun at more 12 months), elbow flexion can be re- Patients with CS-Tl type injuries have g
than one level, and patients typically stored by a free-functioning single the best chance of orthotic success be- c
have a combination of pre- and post- gracilis transfer neurotized by the spi- cause motor loss, not sensory loss, is

Chapter 23: Brachia! Plexus Injuries: Surgical and Prosthetic Management 291
significant. Although the finger flex- The use of a double free-

ors and intrinsics are paralyzed, sen- functioning gracilis muscle transfer
:s sory loss is limited to the ring and described by Doi and associates8 has
small fingers, neither of which are in- given the hope of prehension to pa-
volved in pinch prehension. tients with complete plexus lesions.
The goals of this two-stage operation
7 Complete Plexus Injury are to restore elbow flexion and ex-
1e The complete plexus type injury has tension, as well as wrist extension and
>t the greatest loss of function. Not only finger flexion . In tile first stage, tile
d is the arm totally flail and anesthetic plexus is explored and a free-
te functioning gracilis is harvested and
but chronic pa in is also frequently
J. present. Prior to the advan ces of bra- neurotized by the spinal accessory
·d nerve (Figure 11 ). The gracilis is at-
chia! plexus surgery during the past
1-
decade, these patients had the lowest tached proximally to the clavicle and
,n it is routed distally under the brachio-
long-term success rate, regardless of
1e radialis and flexor carpi ulna ris pulley
treatment. Historically, these patients
)- to the radial wrist or finger extensors.
were relegated to transhtuneral am-
)r The vascular anastomoses are to the
putation plus shoulder fusion and
:d a prosthesis.11 ,13, 1s,19,2s,21,2s,6s Out- thoracoacromial artery and venae co-
In m itantes. The suprascapular nerve
comes for this group have greatly im-
can be neurotized with the accessory Figure 11 Reanimation of the complete
proved, however, witl1 more complex
phrenic nerve, if present (as in 25% to brachia! plexopathy. In this two-stage
neurotizations, the ability to use ex-
38% of patients). Approximately 2 to procedure, t he first stage involves explo-
ve traplexal nerve sources (phrenic, con- ration of the plexus and a free-
3 months later, the second stage is
tralateral C7), and free-functioning functioning muscle transfer for elbow
th performed (Figw·e 12). The second
muscle transfers. 8,29,33,35,46-48,57 In flexion and wrist extension. Th e con-
)Il gracilis is harvested and the motor tralateral gracilis is harvested along w ith
this group of patients, the smallest
1d and sensory intercostal nerves from its motor nerve. The proximal end of the
·a- gains in function make significant
ribs tilree through six are harvested. gracilis is secured to the lateral clavicle,
en improvements in clinical outcome_ and the artery and vein are anastomosed
The gracilis is attached proxi mally to
>f- In complete avulsion of the plexus th e second rib and is routed subcuta- to t he thoracoacromial vessels. The graci-
(CS through C8, Tl), the main goal of lis is neurotized by t he spinal accessory
:e- neously along the medial side of the
surgery is to restore elbow function, nerve (cranial nerve XI). The distal tendon
1is arm and attached to the flexor ten- portion of the gracilis is placed under the
1se followed by shoulder abduction. dons. Then, it is neurotized with two brachioradialis and is woven into the ra-
of Within 6 months of injury, and bar- of the motor intercostal nerves. T he dial wrist extensors. (Reproduced from
~se ring any intraplexal nerve injury, sev- sensory intercostal nerves are neuro- the Mayo Foundation, Rochester, MN.)
ne eral neurotization plans can be pur- tized to the median nerve to provide
lCh sued. One basic approach with palmar sensation. The transferred ate an elbow puUey, bowstringing of
~x- limited goals of shoulder stability and gracilis is vascularized by the thora- the first gracilis muscle transfer at the
tor abd uction with elbow flex:ion is the codorsal vessels. The remaining two elbow gradually occurs, limiting
!U- neurotization of the suprascapular motor intercostal nerves a.re neuro- strength and motion, resulting in an
:en nerve with the spi nal accessory nerve tized to the radial nerve innervating
elbow flexion contracture. We detach
tor and the musculocutaneous motor the triceps.
the distal portion of the flexor carpi
nerve with intercostal nerves. Adding We have slightly modified tile dou-
a hemi-cross C7 neurotization ex- ulnaris and create a pulley at tile level
Ion ble free-functioning muscle transfer
of the proximal forearm as described
fol tended by a vascularized ulnar nerve originally described by Doi and
by the late David Khoo, MD (personal
,ig- graft to tile median nerve provides associates. 7 •8 •40 - 42 ' 59' 60 •64'66 In the first
us- potential wrist and finger flex:ion and communication, 1996) (Figure 13).
stage, we secure the gracilis muscle to
ns- sensibility in the median nerve distri- the wrist extensors as opposed to fin- This technique creates a more effec-
to bution. Altematively, the neurotjza- ger extensors; we believe that this tive pulley and should improve mus-
ch- tion of the suprascapular nerve with helps promote finger flexion through cle excursion and strengthen wrist ex-
of the phrenic nerve, spinal accessory a tenodesis effect. In addition, we tension.
yo- nerve to the musculocutaneous motor have altered the route of the first gra- When transferred for elbow flex-
ow. nerve (elongated witil a sural nerve cilis muscle transfer to create a more ion, the major vascular pedicle should
.ave graft), and neurotization of the inter- effective pulley at the elbow using the be placed in proximity to the thora-
be- costal nerves to the median nerve can flexor carpi ulnaris muscle. When the coacromial trunk in the infraclavicu-
,, is be performed. brachioradialis muscle is used to ere- lar fossa. To d o so, the proximal graci-

tim<
plat
resu
nifi<
rep~
rien
Doi
COV<
digi
thre
bee.
afte
othc
Figure 13 When the brachioradialis mus- bili1
cle is used to create an elbow pulley,
avu.
bowstringing of the first gracilis muscle
transfer at the elbow gradually occurs, C7
t hus limiting strength and motion and re- witl
sulting in an elbow flexion contracture. duil
A B To create a more effective pulley, the dis-
tal portion of the f lexor carpi ulnaris is Po:
Figure 12 The second stage of the double free-functioning muscle transfer is per- detached and a pulley is created at the
formed 6 to 8 weeks later and involves harvest of the second ipsilateral gracilis. A, The level of the proximal forearm. (Repro- Pos
proximal end of the gracilis is secured to the lateral aspect of the second rib, and the duced from the Mayo Foundation, Roch- hav
vessels are anastomosed to the thoracodorsal vessels. The intercostal nerves from ribs ester, MN.) 6 II
three through six are harvested, and the motor and sensory branches are separated. The
teri
motor intercostal nerves from ribs three and four are neurotized into the motor branch
for the triceps muscle, and the motor nerves from ribs five and six are neurotized into
neu
des transferred for combined motion
the free gracilis muscle. B, The sensory intercostal nerves are then neurotized into the ries
(first stage of the Doi procedw·e) witl
lateral cord contribution to the median nerve. The gracilis is tunneled under the medial
aspect of the arm, and the tendon is woven into the flexor digitorum profundus and achieved c: M4 elbow flexion strength trea
= =
flexor pollicis longus tendons. M motor intercostal nerve, S sensory intercostal nerve. (P > 0.05). This result is not surpris- roti
(Reproduced from the Mayo Foundation, Rochester, MN.) ing in that the muscles must use some qui
of their strength and excursion to ex- ma1
lis tendon is passed beneath the tend the wrist or digits and invariably allo
reconstrnctive effort performed in
lose some effect because of bow- pro
clavicle and secured to its superior two separate, lengthy surgical proce-
stringing at the elbow. is i
border. It is tunneled subcutaneously dures. When performed soon after in-
Grasp function after the double in
to the antecubital fossa, where it is jury in patients with avulsions of four
free-muscle procedure relies on re- gra
later secured to the biceps tendon. or five nerve roots, this procedure of-
covery of some triceps function to the
The obturntor nerve branch to the fers the possibility of hand grasp and
stabilize the elbow during contraction ner
gracilis may be repaired to the spinal release, sensory recovery in the hand,
of the gracilis muscle. Thus, this pro- spii
accessory nerve or to two intercostal and active elbow flexion and exten-
cedure is most successful i11 patients mu
motor nerves, either of which shouJd sion.
with adequate muscle strength and
be harvested if possible to allow direct Using a double free-muscle trans- Ot
absence of significant adhesions. In
nerve repair distal to the clavicle. fer, Doi and associates 8 were able to the series by Doi and associates, 8 65% To
We recently reported the results of restore good to excellent elbow flex- of patients achieved more than 30° of she
single free-muscle transfers per- ion in 96% of their patients. In our tio1
total active motion of tl1e fingers with
formed at our institution.67 Of 15 pa- experience, eight patients have had at the second muscle transfer. Such spa
tients who underwent these transfers, least 1 year of follow-up after the function allows only rudimentary pie
14 had recovered at least M3 strength second-stage transfer. Transfer for grasp in many patients. Grasp func- are
based on more than I -year follow-up. combined elbow flexion and wrist ex- tion, however, is difficult to achieve tra:
Of these 14 patients, all but one had tension lowered the percentage of pa- with other methods. Previous efforts tra:
an arc of motion of 90° or greater and tients achieving ;;:: M4 elbow flex:ion at restoring prehension in patients tor
could support a 2-kg weight. The strength compared with elbow flexion with a brachia] plexus injury have pat
transfer of two free-functioning gra- alone. In our patients, 79% of the been unsuccessful because of the long inj1
cilis muscle grafts, combined with free-functioning muscle transfers for length of nerve that must be repaired anc
nerve transfers for triceps function elbow Hexion alone (single transfer) and the prolonged tin1e of reinnerva- Alt
and hand sensibility, is a demandin g and 63% of similarly innervated mus- tion; this combination may exceed the su~

Ch apter 23: Brachia! Plexus Inj uries: Su rgical and Prosthetic Management 293
time that the injured motor end forward flexion and abduction is not
plates will survive. Therefore, these generally possible. Thus, most of
results must still be regarded as a sig- these patients would benefit from
nificant advance in these otherwise ir- shoulder fusion. Shoulder fusion
reparable avulsion injuries. Our expe- works best when scapular control has
rience is nearly identical to that of been preserved through adequate
Doi. Five of eight of our patients re- function of tl1e serratus anterior and
covered at least 30° of total active the trapezius muscles.69 Occupation
digit motion. Two of the remaining is also a factor. Employment as a
three patients lost the gracilis muscle manual laborer, for example, suggests
because of venous thrombosis soo n that shoulder fusion should be con-
after surgery. Currently, the only sidered. Many patients, however, are
other alternative that offers the possi- best served by leaving the shoulder in
IUS- bility of ha nd function after root its flai l condition if they do not report
ley, avulsion injuries is the contralatcral
;cle
pain from chronic traction and their
urs,
C7 nerve root used in combination occupation makes a mobile flail
re- with a vascularized ulnar nerve con- shoulder more cosmetically accept-
Jre. duit. able than a fused shoulder.
dis-
s is Postganglionic Injuries
the
Postganglionic plexus injuries that Orthotic and
)(0- Figure 14 Microswitch control of an ex-
>eh- have been present for less than Prosthetic ternally powered prosthesis is readily fea-
6 months should be treated with in-
terposition cable grafting or selective
Considerations sible because only a few millimeters of
motion are required to fully operate ei-
neurotization if possible. These inju- Prosthetic Approaches ther the elbow, the terminal device, or
ion Transhumeral amputation plus shoul- both. In this case, 11 mm of shoulder ele-
ries are often found concomitantly
ue) vation ful ly operates both the electric el-
with preganglionic injuries and thus der fusion is still a viable approach to
bow and the electric hand.
gth treatment with a combination of neu- complete and untreatable plexus le-
ris- rotization and cable grafting is re- sions, although many authors have
1me quired. The use of intraoperative so- noted that a significant percentage of low the patient to reach all four major
ex- matosensory evoked potentials will such patients discard theiJ- prostheses functiona l areas: face, midline,
tbly allow the surgeon to determine if the over time. 10•1 1 Leffert's72 excellent text perineum, and rear trouser pocket.
::>W- proximal portion of the avulsed nerve notes that arthrodesis of the flail or Numerous harnessing variants have
is in continuity with the spinal cord; weak shoulder is widely accepted be- been developed to maximize the lim-
1ble in this situation, intraplexal nerve cause it is both predictable and united excursion remaining after bra-
re- grafting is the treatment of choice. If complicated. However, fusion in- chia) p lexus injuries. 74 Although the
. to the proximal portion of the avulsed creases the leverage on the scapula complicated harnessing that is re-
:ion nerve is not in continuity with the from the weight of the arm plus quired because of tl1e limited active
JrO- spinal cord, neurotization or free prosthesis/orthosis. Leffert suggests motion remai ning after the injury may
ents muscle transfers can be performed. that trapezius and serratus anterior make donning or doffing the prosthe-
and strength must be good {or preferably sis independently more difficult, some
. In Other Considerations normal) to provide sufficient control; patients find body-powered compo-
55% To successfully use the hand, the motion will be smoother if the levator nents a good choice. Unlocking the el-
1°of shoulder must be stable to allow posi - scapulae and rhomboids are also bow mechanism is often inconsistent
Nith tioning of the hand and forearm in functioning. because of limited shoulder move-
:uch space. In most patients with brachia! Rowe73 has noted that shoulder fu - ment, so a friction elbow or nudge
tary plexus injuries, the remaining muscles sion attitudes originally intended for control is frequently used.
JUC- are insufficient for successful tendon pediatric poliomyelitis survivors are With the widespread availability of
jeve tra nsfer abou t the shoulder. Tendon not optimal for brachial plexus inju- externally powered components,75
=arts transfer of the trapezius and the leva- ries. Rowe recommends shoulder fu- limited body excursion is now less
ents tor scapulae has been attempted in sion with the humerus in 20° of ab- problematic. Microswitch control re-
have patients with upper brachia! plexus duction, 30° of forwru·d flexion, and quires only a few millimeters of mo-
long injuries in which rotator cuff, del toid, 4-0° of internal rotation. Fusion in this tion and can be used to operate an
ured and biceps function has been Iost. 68 attitude permits scapular motion, electric hand,76 an electric elbow, or
·rva- Although the shoulder will no longer when combined with motion pro- both 77 (Figure 14). Myoelectric con-
l the sublu.xate inferiorly, active function in duced by the prosthetic elbow, to al- trol may also be feasible because even

294 Section II: Th e Upp er Limb
Figure 15 If two reliableEMG sites are Figure 16 Nerve grafting plus shoulder
available fol lowing a brachia! plexus infusion may result in good elbow control
jury, proportional myoelectric control may and proprioception. A relatively simple
be possible. A multiposition microswitch, self-suspending transradial prosthesis
controlled in this case by a f ew millimeters may be then used to provide grasp even
of chest expansion, allows t he amputee to though t he skin of the residua l limb is in-
direct EMG control to the elbow, wrist, or sensate. (Reproduced with permission
hand motors. Thus, one pair of EMG sig- from Leffert RD: Brachia! Plexus Injuries.
nals provides proportional control of New York, NY, Churchill Livingstone,
three degrees of freedom: flex-extend, 1985, p 176.)
pronate-supinate, and open-close.
Figu
body-powered hook, the force gener- Figure 17 A body-powered elbow ortho- follc
very weak muscles may generate suffi-
ated along the control cable forced the sis provides active flexion and reduces
cient signal to operate an externally
elbow into full flexion. It was neces- shoulder subluxation. An optional lock-
powered device. It can be argued that ing mechanism may be used to stabilize corn
myoelectric control for the terminal sary to use an outside locking joint the elbow in several different positions. pro:
device is preferable for precise grasp. normally intended for elbow disartic- (Reproduced with permission from Lef- the
It may also be possible to use myo- ulation to stabilize the arm; difficulty fert RD: Brachia! Plexus Injuries. New
gras
in operating the lock because of the York, NY, Churchill Livingstone, 1985,
electric control for both elbow and p 153.) tien
hand function (and perhaps for wrist triceps absence was noted. Van Laere arm
rotation as well), but control sites will and associates 76 reported a case com- quit
likely be on the chest or back (Figu re plicated by complete absence of elbow Flail Arm Orthoses trol
15). Advances in available prosthetic and shoulder function. Following sur-
ln view of the substantial percentage
components have multiplied the op- gical arthrodesis of the shoulder, a of amputees with brachial plexus in- Rel
tions available for amputees with bra- switch-operated electric hand and juries who reject prosthetic devices, Moc
chia! plexus injuries and have in- passive friction elbow joints were init has been argued that orthotic resto- suit
creased the percentage of those who corporated into a prosthesis that the ration is an eq ually plausible al- of
can actuate an active prosthesis. patient reportedly used for many daily ternative.70•79"84 Figure 17 depicts one ple.ll
Whether this wilJ result in increased activities. Leffert 72 has reported suc- example of a custom arm orthosis ortr
long-term use remains to be docu- cess with transradial fittings provided that was successfully used when some diet
mented. that the amputee can sense elbow po- useful hand function remained fol- Mu:
l11 the presence of lesions that spare sition. It is all-important to attempt to lowing a partial brach ia! plexus in- PO'A
some elbow function, transradia1 am- preserve the elbow if there is proprio- jury. Wynn Parry85 has reported on sig11
putation is sometimes performed. ceptive feedback from the joint be- his experience with a series of more trol
T his may also be necessary because of cause the usefulness and degree of ac- than 200 patients and states that 70% tior
the original trauma or because of vas- ceptance of the prosthesis will be continue to use a flail arm orthosis cate
cular complications. 76 Prosthetic fit- much enhanced by it. Even if the el- for work or hobby activities after neu
ting is often complicated by residual bow is flail and the skin over the pro- 1 year. Originally developed in Lon- my<
weakness at the shoulder or elbow or posed residual limb is insensate, prop- don during the early 1960s,83 the pov
both. Dralle78 reported on a patient rioception may be intact and a useful Stanmore flai l arm orthosis consists tigu
with good shoulder control and elbow prosthetic fitting may be obtained of a series of modules that can be in- Virt
flexors but no triceps function. \A/hen without residual lin1b breakdown terconnected to provide any degree of fru~
the amputee attempted to operate a (Figure 16). control desired (Figure 18). For the bra,

Chapter 23: Brachia! Plexus Injuries: Su rgical and Prosthetic Management 295
Shoulder g irdle
Upper arm steel and hinge block
Shoulder hinge bracket
Cable c lamp
Cable housing
Elbow lock with steels Figure 19 W hen a body-powered hook is

Lower trough assembly mounted to the Stanmore orthosis, it
f unctions like a prosthesis even t hough
, Palm and wrist support t he f lail arm remains intact. (Reproduced
with permission from Wynn Parry CB:
Brachia/ plexus injuries. Br J Hosp Med
1984;32: 130-139.)
Loc.k control lever
Detachable palm fitting
Figure 18 The Stanmore flail arm orthosis uses a series of modules t o stabilize the arm
10-
following a brachia! plexus injury.
:es
:k-
ize completely flail arm, a body-powered operate a sophisticated device flaw-
ns. prosthetic hook mounted adjacent to lessly in therapy or the clinic but does
ef- the patient's hand is used to provide not use it at home long-term because
ew grasp (Figme 19). In essence, the pa- the small mass of functioning rem-
f35,
tient has a prosthesis over the flail nant muscle becomes totally fatigued
arm.85 Incomplete lesions may re- after 1 or 2 hours of effort.
quire only the elbow or shoulder con- As a result of all these factors, a
trol modules. diagnostic prosthesis 76 is strongly rec-
ommended (Figme 20) and an inter-
Rehabilitation disciplinary team approach encom-
:es, Modern surgical advances have re- aged for these singularly complicated
to- sulted in a much less uniform range cases.77 •80•86•87 A thorough physical
al- of impairment following brachia! examination including manual and
)Oe plexus injuries, and the prosthetist- EMG muscle testing is required to as-
Figure 20 The complex and sometimes
)Sis ortbotist is now faced with an unpre- sess rehabilitation potential. Because
anomalous neuromuscu lar deficits that
,me dictable array of residual functions . patients with brachia! plexus iJ1j uries are commonly associated with brachia!
fol- Muscle transfers sometimes result in often have a lengthy recovery period, plexus injuries often make a prior deter-
in· powerful electromyographic (EMG) most will have become accustomed to mination of prosthetic components im-
on functioning unilaterally, which can possible. In such instances, a diagnostic or
signals suitable for myoelectric con-
evaluation prosthesis allows clinical as-
Lore trol in unexpected anatomic loca- significantly reduce enthusiasm to sessment of patient tolerance for weight,
'0% tions. Nerve transfers further compli- master an adaptive device. It is there- various harness configurations, and com-
osis cate the issue because anomalous fore imperative tl1at the patient be ac- ponent alternatives. Once therapy t rain-
1fter tively involved in all prescription de- ing has been successfully complet ed w it h
neuroanatomy may preclude precise
the evaluation device, t he definitive pros-
,OD· myoelectric control despite a grossly cisions from the outset; witl10ut a thesis design can be determined and pro-
the powerful signal. Finally, muscle fa- motivated and cooperative individual, vided.
sis ts tigue is frequ ently overlooked and even heroic prostl1etic/orthotic inter-
: in- virtually impossible to predict. It is ventions are doomed to failure.
:e of frustrating for all involved when the Wynn Parry8 7 recommends use of ery period, beginning as soon as tl,e
the brachia! plexus injury survivor can a full-arm orthosis during the recov- patient has come to terms with the se-

Figure 21 A, A pelvic hemigirdle is sometimes used to unweight the flail arm; a counterbalanced forearm assembly is characteristic of
a " gunslinger" orthosis. B, For slender individuals, a spring-loaded metal rod attached to a waist belt can help unweight the arm.
c. Cool88 has proposed using the weight of the paralyzed forearm, acting across a f ulcrum near the radial head, to provide a vertical
antisubluxation force to the humerus. (Figure C is reproduced with permission from Cool JC: Biomechanics of orthoses for t he subluxed
shoulder. Prosthet Orthot Int 1989;13:90-96.)
Fi91
to i
ere,
rious and potentiaUy permanent na- proach is ideal in the presence of a principles in mind when evaluating pro
ture of his or her injuries. He also brachia[ plexus injw-y. the patient with a brachia} plexus in- ortl
notes that fitting more than a year af- One alternative is to unweight the jury.
ter injury is much less successful. arm with a strut along the axiJJary Proximal stability is absolutely es-
Robinson 81 has suggested 6 to 8 weeks midline, attached to a waist belt or to sential for successful fitting. The bili
postinjury as the optimal time for a well-molded pelvic hemigirdle. shoulder girdle and elbow flexors of i
orthotjc intervention, ie, "when the Cool88 from the Netherlands has re- must be strong enough to support the to
patient is beginning to accept the im- ported a clever approach using the arm or arm remnant plus the ha\
plications of his or her injury and yet weight of the paralyzed forearm act- orthotic/prosthetic device. If body- tinJ
has not become too one-handed." ing across a fulcrum at the radial head powered control is anticipated, they fo ll
Once surgical reconstruction and level to literalJy lever the humerus must also be able to resist the forces
spontaneous recovery are complete, back into the glenoid fossa (Figure generated during cable actuation. av
amputation and a trial with a pros- 21). Although more than 1,600 pa- This force typically varies between for
thesis can be considered. The decision tients have been fitted in Europe, this 2 kg (4.4 lb) and 10 kg (22 lb), de- use
to choose amputation is always diffi- approach has not been widely used in pending on the grip strength desired Joe
cult; the opportunity to meet another North America. at the terminal device (Figure 22) . ad
brachia] plexus injury amputee who In general, any device for patients When shoulder stability is mar- ha1
has successfully mastered a prosthesis with a brachia] plexus injury should ginal, a triaJ with exercises to improve kn<
may be helpful. Psychological and so- be as lightweight as possible to mini- muscular control may be warranted. anc
cial work consultation may be useful mize inferior shoulder subluxation. Functional electric stimulation can in<l
to help the patient discuss the altered Because external power is often re- also be helpful in strengthening resid- Ort
body image and employment possi- quired, a trial with an appropriately ual musculature. In the absence of
bilities that will follow amputation. weighted test socket can help deter- intrinsic stability, the prosthetic or lat<
The presence of chronic pain compli- mine tolerance for the added weight orthotic device must stabilize the arm pre
cates prosthetic/orthotic intervention. of powered components. by extending well onto the torso. the
In those cases in which humeral trac- Many patients find this approach
Limb Function Prerequisites abc
tion worsens the pain, special care awkward or uncomfortable, although the
must be taken to prevent the weight Simpson 89 has summarized the pre- some will tolerate it (Figtue 23 ). she
of the device from displacing the arm requisites for upper limb function as Although Rorabeck90 has sug-
arr
downward at the shoulder. This is of- follows : gested transhumeral amputation
rea
ten a diffictLlt task because conven- • Proximal stability without shoulder arthrodesis, an un-
tional prosthetic harnessing supports pn
• Placement in space stable shoulder will always compro-
COJ
axial loads via pressure on the ipsilat- • Functional grasp . mise prosthetic function . Surgical sta-
eral trapezius or by encumbering the It is usefu l for both the physician and she
bilization is often the most practical
contralateral shoulder; neither ap- the prosthetist-orthotist to keep these ex.1
approach to providing proximal sta-

Chapter 23: Brachia} Plexus Injuries: Surgical and Prosthetic Management 297
,f
n. Figure 23 Prosthetidorthotic shoulder
al control requires large flanges extending
id well onto the torso, which many patients
Figure 22 A, A body-powered control applies forces along the control cable that tend find cumbersome or objectionable.
to flex the elbow and externally rotate the shoulder. B, The weight of externally pow-
ered components applies elbow extension and shoulder extension forces. In either case,
proximal stability must be provided via muscle strength, surgical fusion, or prosthetid grip forces with mininlal exertion.
orthotic control. Switch control is used when neces-
sary, but myoelectric control generally
s- offers more precise grip force, pro-
bility despite requiring several weeks previously. Again, surgical stabiliza-
:i.e vided that suitable muscle sites can be
of immobilization for the bony fusion tion via fusion may be preferable.
rs found.
1e to occm. Malone and associates77 Elbow placement is more readily
have suggested that postsurgica1 fit- provided by Bowden cable harnessing Sophisticated orthoses can also re-
~e store grasp to the paralyzed hand by
ting with a prosthesis immediately adapted from transhumeral pros-
y- using either mechanical or external
following arthrodesis may be useful. thetic principles or through the use of
ey power. Most are variations of the
Elbow stability can be provided by externally powered components. Be-
:es "wrist-driven" styles originally devel-
a variety of locking mechanisms. Un- cause the weight of the arm/orthosis/
,n.
prosthesis provides a reliable exten- oped for i11dividuals with quadriple-
en fortunately, many orthoses require
sion moment, a locking mechanism is gia (Figure 25). Other approaches in-
.e- use of the uninvolved hand for un-
not always required. A flexion mo- clude mounting a prosthetic hook
ed locking. Wrist stability is readily
ment generated by biscapular shoul- near the palm of the paralyzed hand
achieved because orthoses that fix the
der abduction, for exan1ple, can be and the use of adaptive utensil cuffs
tr- hand in sligh t wrist extension are well for various specific activities.
,ve readily controlled by the patient to
known and well tolerated. Thumb Mastery of any prosthetic/orthotic
precisely counterbalance the exten-
:d. and finger stabilization is determined
sion forces due to gravity. This is par- device is believed to be contingent on
a11 individually by following accepted ticuJai·ly effective when weak elbow its effectiveness in augmenting func-
.d- orthotic principles. flexors are present but shoulder sta- tional activities. Actively including the
of Placement in space is closely re- bility is good. Springs or elastics ca11 patient in the decision-making pro-
or lated to stability and is imperative to also be used to help counterbalance cess, particularly in the choice of spe-
rm
provide a useful work envelope and the weight of the forearm (Figure 24). cific components a11d design options,
so. thereby allow the individual to reach Functional grasp is readily restored increases the success rate. One key to
1ch
above, below, in front of, and behind in a variety of ways. Body-powered long-term usage is to identify specific
.gh
the body. In cases where residual hooks of the voluntaq-openi11g type tasks important to the individual that
shoulder musculature can steady the are the traditional approach and are will be facilitated by using the device.
1g-
arm but not support its weight when often effective. In addition to being A major limitation of all cw-rent
.o n
tn-
reaching out, the utility of the lightweight and durable, they provide prosthetic/orthotic grasp modalities
prosthetic/orthotic device is severely a constant, limited pinch force with- is the absence of sensation, which re-
ro-
compromised. Orthotic control of the out continued exertion by the patient. quires close attention to visual cues
ta-
shoulder is cumbersome and requires Electric hands or hooks are increas- by the user. As Simpson89 has noted,
cal
extensions onto the torso, as noted ingly common and offer powerful when control of the arm becomes the
ta-

result. Early provision of a flai l arm

orthosis may be useful to encourage
two-hru1ded activities during the re- 7
covery phase. Timely surgical inter-
vention should enhance residual
function.
Leffert7 2 has emphasized the in1-
portance of educating brachial plexus 8
injury survivors who are considering
prosthetic fitting about what is realis-
tically possible. Patients often come
with totally unrealistic ideas of
"bionic arms" depicted in the popular
medfa. Unless they give up such fan-
9
tasies, they are unlikely to be satisfied
with their results. Whenever possible,
patients with brachia! plexus injuries
10
Figure 25 Orthoses originally designed contemplating amputation should
for individuals with quadriplegia may be have the opportunity to see and talk
useful following brachia! plexus injuries. with other patients who have already
This version uses switch control to oper-
undergone the procedure.
ate a miniature electric motor that opens
and closes the fingers. The ideal environment to manage 11
brachia] plexus injuries is a multidis-
ciplinary clinic specializing in this
work of the pioneers of brachial most challenging problem. Despite
plexus surgery during the past several recent advances in both surgical and
Figure 24 Biscapular shoulder motion decades, a better understanding of prosthetic-orthotic technique, many
may sometimes be harnessed to provide these injuries and novel approaches to individuals with brachia! plexus inju- l:;
active elbow flexion despite significant treatment have emerged. These ad- ries will find that the functional capa-
paresis. Various mechanical flexion assists
can help counterbalance the weight of
vances have given both patients and bilities of the affected limb remain
the forearm and hand. (Reproduced with surgeons new options that offer hope significantly limited because of the I:
permission from Leffert RD: Brachia! for improved clinical outcomes. magnitude of the functional loss they
Plexus Injuries. New York, NY, Churchill Despite recent surgical advances, have sustained.
Livingstone, 1985, p 153.) brachia] plexus injuries present one of
the greatest challenges to the rehabili-
tation team. Providing grasp is only References
main task, the rate of rejection in-
the first step and is often the easiest to l. Allieu Y, Cenac P: ls surgical interven-
creases significantly. The difficulties
accomplish. Practical restoration of . tion justifiable for total paralysis sec-
involved in using the insensate ondary to multiple avulsion injuries of
"blind" hand are well documented. the ability to place the arm in space
the brachia! plexus? Hand Clin 1988;4:
The alternative of teaching the indi- can be difficult, while provision of ex- 11
609-618.
vidual with a brachia! plexus injury ternal shoulder stability is cumber-
2. Allieu Y, Privat JM, Bonnel F: Paralysis
some at best. Surgical stabilization by
one-handed independence should al- in root avulsion of the brachia! plexus:
shoulder fusion should always be care-
ways be carefully considered and is Neurotization by the spinal accessory
fully considered if functional use of nerve. Clin Plast Surg 1984;1 I: 133-136.
frequently the most effective solution
the affected limb is desired. Residual
long term. 91 3. Azze RJ, Mattar Junior J, Ferreira MC:
neuromuscular deficits make fitting et al: Extraplexual neurot ization of
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Conclusion jury a complicated undertaking. The 28-32.
use of a diagnostic prosthesis before 4. Brandt KE, Mackinnon SE: A tech-
Injuries to the brachia! plexus can be determination of the final prescrip- nique for maximizing biceps recovery
devastating and often drastically tion is highly recommended because in brachia! plexus reconstruction.
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Chapter 23: Brachial Plexus Injuries: Surgical and Prosthetic Management 299
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rage L0:993-997. with a brachia! plexus injury. Neurol Intercostal nerve transfer to restore
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lter-
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dual
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im-
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exus
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:ring
double free muscle technique follow- Su,gl984;11 : l 15-120. rongwan V: Restoration of elbow flex-
:alis- ion in brachia! plexus avu lsion injury:
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ome Comparing spinal accessory nerve
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36. 1996;21:1071-1077.
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; they ual paralysis after brachia! plexus le- Med 1974;67:488-490. vated free muscle transplantation for
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29. Chuang DC: Neurotization procedures
Reconstr Surg I 993;91:872-883.
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ble free-muscle transfer to restore pre-
15. Yeoman PM, Seddon HJ: Brachia! 30. Chuang DC, Yeh MC, Wei PC: Inter-
rven- hension following complete brachia!
plexus i11juries: Treatment of the flail costal nerve transfer of the musculo-
sec- plexus avulsion. J Hand Surg {Am]
arm. J Bone Joint Surg Br I 961;43:493- cutaneous nerve in avul.sed brachia!
ries of l 995;20:408-414.
500. plexus injuries: Evaluation of 66 pa-
988;4: tients. J Hand Surg {Am] 1992;17: 42. Doi K, Sakai K, Kuwata N, et al: Re-
16. Carvalho GA, Nikkhah G, Matthies C,
822-828. construction of finger and elbow
et al: Diagnosis of root avulsions in
ralysis 31. DolencW: lntercostal neurotization
function after complete avulsion of
traumatic brachia! plexus injuries:
>lexus: of the peripheral ne rves in avulsion the brachia! plexus. J Hand Surg {Am]
Value of computerized tomography
ssory plexus injuries. Clin Plast Surg 1984; 1991;16:796-803.
myelography and magnetic resonance
3-136. imaging. J Neurosurg I997;86:69-76. 11 :143-147. 43. Samardzic M, Grujicic D, AnttlOovic
1MC: 32. Hattori Y, Doi K, Fuchigami Y, et al:
V, et al: Rein nervation of avulsed bra-
17. Doi K, Otsuka K, Okamoto Y, et al:.
of Experimental study on donor nerves chia! plexus using the spinal accessory
Cervical nerve root avulsion in bra.-
~4;)5: for brachia1 plexus injury: Compari- nerve. Surg Neurol 1990;33:7-11 .
chial plexus injuries: Magnetic reso-
nance imaging classification and com- son between the spinal accessory nerve 44. Gu YD, Ma MK: Use of the phrenic
:h- parison with myelography and and the intercostaJ nerve. Plast nerve for brachia! plexus reconstruc-
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n. grapby. J Neurosurg 2002;96: 33. Merrell GA, Barrie KA, Katz DL, et al: 45. Gu YD, Zhang GM, Chen DS, et al:
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1d Surg Magnetic resonance myelography in function i11 the context of a meta- treatment of brachia! plexus root avul-
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Cross-chest C7 nerve grafting fol- chia! plexus. JHand Sttrg [Am] 1996; Orthoses in patients with brachia]
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chia! plexus injuries: A preliminary muscle transplantation combined with 71. Ransford AO, Hughes SPF: Complete t
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et al: Ne rve transfer to biceps muscle transplantation, in Manktelow RT al: A prosthetic appliance for a patient
using a part of ulnar nerve for C5-C6 (ed): lvficrovascular Reconstruction: witl1 a brachia! plexus injury and fore-
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tomical study and report of four cases. Techniques. New York, NY, Springer- Occup Ther 1977;31:309-312.
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51. Chuang DC, Lee GW, Hashen F, et al: 62. Manktelow RT, Zuker RM, McKee al: Brachia! plexus injury management
Restoration of shoulder abduction by NH: Functioning free muscle trans- through upper extremity amputation
nerve transfer in avulsion brachia! plantation. J Hand Surg [Am] 1984; with immediate postoperative pros-
plexus injury: Evaluation of 99 pa- 9:32-39. theses. Arch Phys Med Rehabil 1982;63:
tients with various nerve transfers. 89-91.
63. Berger A, Flory PJ, Schaller E: Muscle
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transfers in brach ia[ plexus lesions.
52. Krakauer JD, Wood MB: Intercostal J Reconstr Microsurg 1990;6: 113-116. below-elbow amputation with bra-
nerve transfer brachial plexopathy. 64. Doi K: New reconstructive procedure chial plexus injury. Orthot Prosthet
J Hand Surg (Am} 1994;19:829-835. 1977;31:39-40.
for brachial plexi.1s injury. Clin Plast
53. Leechavengvongs S, Witoon CK, Uer- Surg 1997;24:75-85. 79. Chu DS, Lehneis HR, Wilson R: Func-
pairojkit C, et al: Nerve transfer to tional arm orthosis for complete bra-
65. Shurr D, Blair W: A rationale for treat-
biceps muscle using a part of the ulnar chia! plexus lesion. Arch Phys Med
ment of complete brachia! plexus
nerve in brachia! plexus injury (upper Rehabil 1987;68:594.
palsy. Orthot Prosthet 1984;38:55-59.
arm type): A report of 32 cases. J Hand 80. Frampton VM: Management of bra-
66. Doi K, Hattori Y, Kuwata N, et al: Free
Surg [Am] I 998;23:711 -716. chial plexus lesions.} Hand Ther 1988;
muscle transfer can restore hand func-
l:115-120.
54. Mikami Y, Nagano A, Ochiai N, et al: tion after injuries of the lower brachia!
Results of nerve grafting for injuries of plexus. J Bone Joint Surg Br 1998;80: 81. Robinson C: Brachia! plexus lesions:
the axillary and suprascapular nerves. 117-120. Part I. Management. Br J Occup Ther
J Bone Joint Surg Br 1997;79:527-531. 1986;49: 147-150.
67. Bishop AT, Barrie KA, Steinmann SP:
Gracilis free muscle transfer for resto- 82. Robinson C: Brachia! plexus lesions:
55. Narakas A, Hentz VR: Neurotization Part 2. Functional spfjJHage. Br J Occup
in brachia! plexus injuries: lndication ration of function following complete
Ther 1986;49:331-334.
and results. Clin Orthop 1988;237: brachia! plexus avulsion. Presented at
the 56'h Annual Meeting of the Ameri- 83. Wardlow M: A modular orthosis for
43-56.
can Society for Surgery of the Hand, brachia] plexus lesions. Inter Clin Info
56. Ruch DS, Friedman AH, Nunley JA: October 4-6, 200 I, Baltimore, MD. Bull 1979;17:9-12.
The restoration of elbow flexion with 68. Saha A: Surgery of the paralyzed and 84. Wynn Parry CB: The management of
intercostal nerve transfers. Clin Orthop flail shoulder. Acta Orthop Scand 1967; injuries to the brachia! plexus. Proc R
I 995;314:95-103. 97:5-90. Soc Med 1974;67:488-490.
57. Songcharoen P, Mahaisavariya B, 69. Leffert R, Seddon H: Infraclavicular 85. Wynn Parry CB: Brachial plexus inju-
Chotigavanich C: Spinal accessory bracnial plexus injw·ies. J Bone Joint ries. Br J Hosp Med I 984;32:130-139.
neurotization for restoration of elbow Surg Br 1965;47:9-22.

.....
Chapter 23: Brachia] Plexus Injuries: Surgical and Prosthetic Management 301
86. Shurr DG, Blair WF: A rationale for 88. Cool JC: Biomechanics of orthoses for 90. Rorabeck CH: The management of the
treatment of complete brachia! plexus the subluxed shoulder. Prosthet Orthot tlail upper extremity in brachia! plexus
palsy. Orthot Prosthet 1984;38:55-59. Intl 989;13:90-96. injuries. J Traurna 1980;20:491-493.
87. Wynn Parry CB: Rehabilitation of pa- 89. Simpson DC: The hand/arm system, 91. Frampton VM: Management ofbra-
tients following traction lesions of the in Murdoch G (ed }: Prosthetic and chial plexus lesions. Physiotherapy
brachia! plexus. Clin Plast Surg 1984; Orthotic Practice. London, England, 1984;70:388-392.
11: 173-179. E Arnold, 1968.
et
nt
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et
mt
53:
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l-
188;
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~9.

Aesthetic Prostheses
Thomas Passero, CP
Kim Doolan
Int roduction
The importance of prosthetic appear- and design that are most likely to suc- Function
ance and function cannot be overem- cessfully meet the needs of the pa-
phasized and is well docmnented. 1- 10 tient. The functional capabilities of aes-
Often, an amputee more readily ac- The prosthesis should reproduce a thetic prostheses are surprisingly
cepts and uses a prosthesis if it mim- complex and vary with the level of
realistic appearance with regard to
ics the appearance of the lost digit or amputation. Upper limb applications
both textui-e and color. Although a
limb. Aesthetic prostheses are more include manipulative activities such
variety of materials have been used
frequently indicated for upper rather as prehension, pushing, and pulling,
for aesthetic restorations, silicone is
than lower limb amputees, probably as weU as balance, support, stabiliza-
generally preferred because of its ver-
because of the increased visibility of tion, proprioception, and commtuli-
satility, dui-ability, and compatibility cation.1'4'6'8'14'15 Most patients with
the upper limbs during most activi-
with human tissue. 5• 11 · 13 Ideally, pros- an upper limb prosthesis use the en-
ties.
theses should be custom made to inti- tire surface of the prosthesis and not
Misconceptions regarding tl1e role
mately fit the contours of the residual just the terminal device. Common ex-
of aesthetics in the selection of a
prosthesis are common. An aesthetic digit or limb. amples include stabilizing a book on
or cosmetic restoration is sometimes the forearm, sandwiching a grocery
considered to be a last resort that is bag between the hip and prosthesis,
offered only if the patient rejects History and pushing up from a chair by plac-
mechanical devices. A comprehensive In the 1950s, the French physician ing weight against the prosthetic el-
treatment plan, however, considers all bow.
Jean Fillet emphasized the profound
available prostheses appropriate for Although active prehension with a
impact of the loss of even a single
the type and level of amputation, in- prosthetic hook or hand is critical for
digit on the amputee's body image,
cluding aesthetic prostheses. A thor- bilateral upper limb amputees, it is
self-esteem, and psychological status.8
ough examination, combined with less importan t for many unilateral
He established clinics around the
careful assessment of the amputee's arm amputees. Several studies have
world and pioneered the use of sili- confirmed that active grasp and re-
goals and desires, enables the health
cone prostheses that were scul pted lease does not occw- continuously,
care team to prioritize restoration of
normal appearance among the crite- and painted to match the individual even for excellent prostl1etic users. "If
ria for prosthetic design. patient. Twenty years later, Horst active manipulation of a terminal de-
The prescription for a prosthesis is Buckner, a German prosthetist, devel- vice is seen as the determinant for
based on the anatomic state of the re- oped a new method to cover mechan- good prosthetic use, then the number
sidual limb, including the level of am- ical prosthetic components, such as of 'good' users found would be less
putation, length, shape, and range of body-powered and electric hands, than 25%." 1 Several international tri-
motion. The intended functional out- with lifelike silicone skins. Today, als have reported that 58% to 76% of
comes or uses of the prosthetic de- many fabrication techniques use mul- the amputees studied wear their pros-
vice(s) are also key considerations. tiple grades of silicone, and aesthetic thesis for at least 8 hou1·s each day. 1 •4
The prescription process should prostheses are produced at both large The inevitable conclusion is that a
identify the prosthetic components and small facilities. person wearing a prosthesis finds a

use for it, including activities that do limb amputees who cannot conceal gues for expanding the role of the
not involve active grasp and release. 4 their changed body as easily as lower prosiliesis to indude more than just
The potential functions of an aes- limb amputees. A prosthesis with a grasping actions. "ff tl1e role of the
thetic prosthesis depend on the com- natmal appeaJance allows patients to prosthesis in supporting, stabilizing,
plexity of involvement (ie, unilateral blend in and not be singled out as dif- pushing, pulling, holding, and facili-
or bilateral amputation) and the use ferent, even when usi ng ilieir prosthe- tating balance in everyday life situa-
of passive, mechanical, or electric sis in public. Once the amputee has tions is accepted as more useful than
components. A single aesthetic pros- accepted the change in body image, that of manipulation of small objects
thesis used on an index finger, for ex- wearing more obvious terminal dein the clinic situation; th is could ... in-
ample, actively functions in prehen- vices, such as hooks or electrically fluence training" as well as tl1e design
sile activities such as writing and powered grippers, may be more ac- of componentry and composition of Figu
grasping small objects, or dming acceptable. Unfortunately, some ampu- surface and subsmface materials.
tivities requiring striking, such as use tees who were provided with metal Thus, traini11g must not be limited to
of a keyboard. 8 A partial hand pros- tool-like devices shortly after the am- controlling prehension, particularly
lni
thesis for a hand without a thumb putation later report having felt so for patients with a unilateral arm am- The
and forefinger provides functional self-conscious that once rehabilitation putation. Hubbard and associates 2 ar- sam
opposition to the remaining fingers . was completed, their prosthesis was gue iliat most unilateral amputees use thes
For the unilateral total hand amputee, placed in a closet and never worn their prosiliesis as gross motor assists, asse.
an aesthetic hand prosthesis provides again. Pillet and Mackin8 expressed not for fine motor activities. is d,
opposition to the sow1d hand while the importance of personal appear- The therapist best serves the am- thes
performing bimanual activities. In ance to the patient as follows: "Often putee by using protocols that not only liml
addition, a prosthetic hand can be the disfigurement is more pro- teach control of prosthetic compo- thet
used to communicate, balance, stabi- nounced in the mind of the amputee nents ( terminal devices, wrists, el- com
lize, and push or pull objects without than others. However, the man who the
bows, shoulders) but also how to
active grasping. finds himself unable to take his hand ably
most efficiently complete activities of
Aesthetic prostheses for lower limb from his pocket, even though it is liml
daily living and occupational tasks.
amputees have some limitations be, very 'functional,' may be as hancti- acce
These activities incl ude using the ex-
cause they can interfere with the mu1- capped as if it were lost." lirnt
terior of the artificial limb to stabilize,
tidirectional forces and motions gen- is to
lift, move, and compress external ob-
erated during ambulation. L6 •17 This pen:
jects. These latter functions are
will be discussed in a subsequent sec- Early Fitting and resic
readily accomplished with aesthetic
tion. Rehabi I itation loss
prostheses.
<lisp
The importance of fitting a prosthesis
Psychological som
as soon after amputation as possible off t
Considerations is well established. Malone and asso- Patient Compliance ses
ciates LS wrote that the first monili af-
A prosthetic limb with a realistic ap-
ter amputation should be considered
With Prosthetic Use wan
pearance provides subtle psychosociaJ fitti.J
the "golden period" during which fit- In their classic study, Millstein and as- and,
advantages, simi lar to the nonfunc-
ting of an upper limb prosthesis sociates6 wrote, "For any prosthesis to brea
tional advantages provided by the
would lead to the best lo ng-term out- be accepted and used by the amputee,
painted pupil, iris, and sclera of a
come. Amputees who have delayed it must be comfortable, functional,
prosthetic eye. An aesthetic prostl1esis Co
fittings do not seem to master the use and have a pleasing appearance."
partially restores both the active and
passive functional capabilities that
of their prostl1esis as thoroughly or Other characteristics described as pri- Pri
use it as spontaneously as do ampu- orities include light weight, durabil-
were lost with amputation, including
tees who have been fitted shortly after ity, ease of clean ing, longevity of op-
Lir
normal appearance.
surgery. eration (up to 12 hours), and Mal
Whether small parts or entire
suitability for driving. Amputees aJso ther
lengths of limbs are removed, it is im-
frequently request that the prosthesis scri1
possible to pred ict an individual's re-
action to determine what prosilietic
Therapy be as wmoticeable as possible and not part
Expert training in the effective use of get in tl1e way. Consideration of these proi
designs will best meet his or her
factors when choosing the type of stor
needs. A patient may do better if ini- prostheses to replace the hand or en-
prosthesis and related components corr.
tially provided with a prosthesis that tire arm is important to ensme that
increases ilie chances that the patient lost.
mimics the appearance of the lost the patient receives the full potential
reh,
limb. This is especially true of upper benefit of the prostl1esis. Fraser 1 ar- will wear the prosthesis.

Chapter 24: Aesthetic Prostheses 305
he
1st
he
,g,
ili-
1a-
lan
cts
in-
ign Figure 2 Silicone f ingernail.
of Figure 1. A, Index figure prosthesis. B. Index fig ure prosthesis in use.
als.
I to has advantages, 21 including increased
1rly
Initial Assessment providing prosthetic devices that are
optimized for different specific activi- pinch force and the transfer of deep
1m- The initial patient assessment is 11:.he ties and situations. Different upper pressure sensation. The risks of os-
ar- same regardless of the type of pros- limb prostheses are increasingly being seointegration are tl1e same as those
use thesis under consideration. Once the used for different activities. Some for oth er similar surgical procedures.
lStS, assessment has been completed and it transradial amputees, for example, This procedure is especially useful
is determined that an aesthetic pros- will use a myoelectric prosthesis with w hen the length of the residual digit is
~m- thesis is indicated, then the resid'Ual an electronic gripper at work when insufficient for retention of a conven-
>nly limb must be prepared for the pros- powerful prehension is of the utmost tional prosthesis. Other means of re-
1po- thetic fitting. The wound should be in1portance. A more basic body- taining prostheses o n short residual
el- completely healed, and the volume of powered prosthesis with a cable- limbs include medical adhesives, in-
to the residual limb should be reason- operated hook may be used in the corporation of vacuum chambers in
:s of ably stable. Wrapping the digit or workshop because of its rugged na- the distal portion of the prosthesis, 22
1sks. limb with a compressive material will tu re, and an aesthetic prosthesis or use of adjacent finger(s) and rings
. ex- accelerate volume reduction. The might be used for social occasions. to anchor th e prosthesis to the hand in
lize, limb volume must be stable if suction a manner simjJar to that used for a
is to be used as the sole means of sus- Finger Prostheses dental crown ai1d bridge.
ob-
are pension. If significant atrophy of the Finger and partial finger an1putations Suction is the primary means of
1etic residual limb occurs, the subsequent are among the most common types of suspension for most finger prosthe-
loss of the vacuum seal will result in partial hand loss.5 The National Lin1b ses. T herefore, the residual finger
displacement of tbe device and, in Loss Information Center indicates must have an approp riate shape (ide-
some instances, the prosthesis will fall that 88% of the 26,000 upper limb ally, cylindrical or bu lbous) and be of
off the arm or digit. Even for prosthe- amp utations in 1996 involved the loss sufficient length, usually at least l to
ses not suspended by suction, un- of fingers. 1.5 cm. 5 •8 Suspension by suction is
wanted movement within a loose- The benefits of silicone restoration usually unreliable wit11 shorter resid-
fitting socket can affect function of digital amputations are well docu- ual digits that have a conical shape. In
d as-
a11d/or cause skin irritation and mented and include a range of func- such situations, the previously men-
sis to
breakdown. tional and psychological improve- tioned alternate methods could be
,utee,
ments, in addition to a much more used. If the involved hand has multi-
anal, normal appearance 7 •9 • 19•20 (Figure 1). ple short residual fingers, it may be
,,
1nce. Considerations for The length of the remaining finger necessary to cover the entire hand
s pn- Prostheses for Upper or fi ngers is a primary consideration witl1 an aesthetic glove to create a de-
rabil- in the selection of the method of sus- vice that is firm enough to withstand
f op· Limb Amputees
pension (suction or mecha11ical), the force required to grasp and hold
and Malone and associates 18 observed that length of the prosthesis (whetl,er the objects.
s also there is no standard prosthetic pre- proximal edge of tl1e prosthesis term i- If the residual digit has sufficient
thesis scription for upper limb amputees. In nates at the proximal interphalangeal length, a half finger prosthesis is pre-
,d not part, this is because no upper limb or metacarpophalangeal joint), shape ferred by most patients. A half finger
these prosthesis, however elegant, can re- of the restoration, and use of either a prosthesis terminates at the proximal
pe of store more than a small portion of the hard acrylic or soft silicone fingernai l. interphalangeal join t and has a feath-
men ts complex functions that have been Although suction is the primary ered proximal edge to minimize the
atient lost. An optimal level of fu nctional means of retention of most djgital transition between the silicone and
rehabilitation is often achieved by prostheses, the use of osseointegration the natural tissue and to avoid lin1it-

Figure 3 A partial hand device (A) can be used to perform tasks of daily living (B).
Figure 5 Roll-on suction liners with me-
chanical locking mechanisms allow the
patient to interchange multiple terminal
devices, including an aesthet ic hand pros-
thesis with internal armature.
Figu
the flexible silicone skin of the pros-

thesis. The armatw·e is often made of
braided stainless steel, but other ma- tial
terials can be used as long as they are vidi
sufficiently durable to be repeatedly finE
reshaped by the amputee. Armatures dur
allow the amputee to flex or extend ties
the fingers of the prosthesis, effec- mo:
tively positioning them for specific ma;
tasks. ma1
Figure 4 A, Dorsal view of hand and mold for prosthesis. B, Palmar view of hand and spa,
mold.
Partial Hand Prostheses it 6
A partial hand prosthesis should be Fu
ing joint range of motion. When the nails, silicone nails should not be
considered for either acquired or con-
length of the remaining digit is insuf- painted. In addition, the silicone can- Pat:
genital deficiencies i11 which there is
ficie nt to secure a half finger restora- not be extended beyond the Length of the
total loss of one or more digits at or
tion, a full finger prosthesis terminat- the fingertip. sis.
proximal to the metacarpophalangeal
ing at the metacarpophalangeal joint full
Thumb Prostheses joi11t (Figure 3). When functional dig-
is recommended. A full finger pros- mo
its remain, the design must be care- lize
thesis may also be used even with a Thumb prostheses present unique
fully optimized to minimize interfer- ber
more distal amputation when antici- challenges because of the desired mo-
ence with their movements. Proximal
pated activities will generate sufficient bility and stability of the prosthesis. 5 dee
termination of the prosthesis is usu- me,
forces to displace a half finger restora- A full-length prosthesis is generally
tion. Because the termination of a full indicated to maintain adequate stabil- ally planned so that a watch or brace- bee
finger prosthesis occurs at the base of ity, given the presence of soft tissue in let can be worn to minimize evidence Jim
the proximal phalanx, a ring can be the web space between thumb and in- of the transition between silicone and sio1
used both to enhance the attachment dex finger and the extreme range of natural skin. mu
and to minimize the transition line. motion and significant force gener- An example of such a restoratio11 is an
A half finger prosthesis is generally ated during prehension. For maxi- shown in Figure 4. The mold depicts a ter1
indicated for patients who have a par- mum stability, a glove-type partial congenital unilateral limb deficiency.
tial nail and nail bed after a distal tip hand prosthesis may be preferable. Design options included exposing the Tn
amputation or for those with an am- thumb aJ1d little finger, which are able Fo1
putation at the base of the nail. An Internal Armatures to oppose and grasp, or compl.etely am
acrylic nail is probably not feasible for In partial or full hand prostheses, a containing them inside of the pros- the
these patients because the mounting semi.rigid internal armature may be thesis. In this case, a fulJ restoration ligl
mechanism protrudes into the pros- added to provide additional stability. that provided the most normal ap- ral
thesis. In this situation, a silicone nail Functionally, the armature adds a pearance was selected based on the US€
can be used (Figure 2). Unlike acrylic skeletal or structmal component to patient's vocational requirements. Th

ne-
t he
in al
ros-
Figure 6 Myoelectric (A) and passive (B and C) transradial devices.
'OS·
~of The use of an armature with a par- assist the sound hand during various
na- tial hand prosthesis is helpful in prn- activities.
are viding firm resistance to the intact An aesthetic restoration is still pos-
:dly fingers, thumb, or opposing hand sible when a mechanical or electric
ires during opposition or bimanual actiivi- hand is provided, but compromises in
ties. In patients who have retained the dimensions and shape of the
end
most of their metacarpals, however, it wrist, palm, and fingers are needed
fec-
may be impossible to provide an ar- because of the configuration of the
:ific
mature because there is insufficient internal mechanisms. These hands
space within the prosthesis to anchor can be covered with a custom-made
it firmly. silicone skin for enhanced cosmesis as
well as active prehension by the ter-
I be Full Hand Prostheses minal device (Figure 6). Silicone cov-
;on- erings resist staining better than the
Patients with amputations through
re is vinyl covers that are typically pro-
the wrist require a full hand prosthe-
1t or vided with these hands.
sis. The major challenge in making a
Lgeal
full hand prosthesis is to identify the
dig- Prostheses for
most effective socket design to stabi-
:are- lize the restoration without encum- Amputations at
rfer- bering the patient.8 During the last Transhumeral and Higher
imal decade, roll-on suction liners with Levels
usu· mechanical locking mechanisms have For passive transhumeral prostheses,
race- been increasingly popular for upper the silicone skin can be made in one
.ence limb prostheses. This type of suspen- piece, encompassing the entire pros-
· and sion allows the patient to interchange thesis up to the axilla. This use of sil-
multiple terminal devices, including icone provides the most realistic
on is an aesthetic hand prosthesis with in- appearance, although the silicone will
icts a ternal armature (Figure 5). inevitably distort unnaturally at the
ency. elbow or shoulder during flexion. A Figure 7 Cutaway of transhumeral de·
g the Transradial Prostheses concealed, internal mechanical elbow vice showing embedded passively oper·
: able ated elbow.
For a patient with a unilateral arm joint is manipulated with the opposite
letely amputation, a passive aesthetic pros- hand, prepositioned, and locked for
prosthesis provides good function, is specific activities (Figure 7).
ation lightweight, and offers the most natu- Silicone coverings most often ter- elbow. A continuous cover to the ax-
1 ap- ral appearance. The sow1d hand is minate at the elbow to minin1ize in- illa creates marked resistance to elbow
[l the used for activities requiring dexterity. terference with movement of the tlexion, which drains the batteries of
s. The passive prosthetic hand is used to body-powered or electrically actuated an electric prosthesis or forces the pa-

and experienced rehabilitation team Considerations for

of physicians, prosthetists, occupa-
tional therapists, and psychothera-
Lower Limb
pists wiU help to optimize clinical Prostheses
outcome. Aesthetic restorations for lower limb
Pillet and Mackin8 have observed an1putations are routinely provided,
that physical impairment is so great although not as frequently as for up-
for the bilateral amputee that it over- per limb amputees. A lower limb
shadows the aesthetic concern, b ut prosthesis can often be easily con-
such a concern is in fact not dimin- cealed under clothing and footwear.
ished in these patients. Most bilateral The material currently used for aes-
.
upper limb amputees initially focus thetic restorations of lower limbs is
on prostheses that restore active not as dura ble as those used for upper
grasp and release. Interest in obtain- limb prostl1eses. Custom aesthetic
ing an aesthetic prosthesis, however, restorations are currently most com-
A
often increases over time, particularly monly used for patients with toe or
for patients living in cultures that partial foot amputations. The aes- Figl
place a high value on physical appear- thetic restorations are more fre- (Coi
ance. quently requested by female than
male amputees. Many lower limb am-
putees have expressed a desire for a
Patients with more lifejjke artificial limb. Efforts to
Congenital develop new lower limb prostheses to
better withstand the forces of ambu-
Deficiencies lation are ongoing.
Parents have great expectations for
Toe, Partial Foot, and Foot
their children and learning that their
newborn has a congenital lin1b defi- Prostheses
ciency can cause them to despair As the extent of the amputation
about their chi ld's future. Fitting an progresses from d istal to more proxi-
infant with a natural-looking prosthe- mal levels of the foot, aesthetic pros-
sis to make his or her appearance theses require internal and/or supple-
more like that of other children can mental structural components to
help the process of parental accep- control unwanted foot movement,
tance. 2·3•8•10 Early prosthetic fitting protect compromised tissue, and dis-
tribute the transmission of forces
encourages the child to use the pros-
Figure 8 Myoelectrically operated device generated during walking. These de-
with custom silicone cover. thesis to meet age-appropriate func-
vices may be called orthoses or pros-
tional milestones. 3
theses because they typically contain
The types of prosthesis fitted may
tient to generate excessive forces to elemen ts of both types of devices 16
vary as the child matures. Most in-
operate a body-powered device (Fig- (Figure 9). These structural appli-
fants begin with passive terminaJ de-
ure 8). ances can then be covered with a cus- Fig
vices, aJthough some are initially fit-
tom silico ne skin to provide an aes-
ted with myoelectrically controlled or thetic external appearance.
Bilateral Upper Limb
body-powered prostheses. Preschool
Prostheses children are often lll1COncemed with Syme, Transtibial, and pr,
The rehabilitation p rocess for a bilat- the appearance of the prosthesis, but Transfemoral Prostheses ini
eral upper limb amputee is more this can change when the child tn,
If the entire foot is lost, the functional
complicated than for patients with a reaches adolescence. Adults with a characteristics of silicone prostheses mi
unilateral limb loss. A bilateral trans- congenital limb deficiency may re- are limited to the psychosocial bene- pr,
humeral amputee has only a 25% to quest an aesthetic prosthesis to facili- fits associated with having a more co
50% likelihood of ach ieving totaJ tate social interactions in work situa- normal appearance. In these patients, eri
independence (DJ Atkins, unpub- tions, particularly if their occupation conventional prosthetic components er:
lished data, 1999, Reno, NV). Refer- involves frequent interactions with are provided. After the prosthesis is <ll
ring these amputees to a specialized the general public. fitted and the dynamic alignment m,

1b
:d,
p-
nb
n-
ar.
!S-
is
,er
tic
n- A
or
es- Figure 9 A, Partial foot over custom fiber sole. B, Patient wearing t he finished foot.
re- (Courtesy of Jack Uel/endahl, CPO.)
.an Figure 10 Transtibial prosthesis. (Cour-
m- tesy of Liberating Technologies Inc, Hol-
:a lister, MA.)
to
to
)U- Nails
Fingernails and toenails can be made
from either a hard acrylic material or
a softer, flexible silicone. The most re-
alistic appearance is achieved with
on acrylic, which can be formed to
,xi- match any nail shape, length, and
os- color. Acrylic nails can also be painted
1le- by the user with commercially avail-
to able nail polish. Silicone nails are soft
:nt, and flexible, cannot be extended be-
lis- yond the tip of the finger, and should
·ces not be painted with nail polish.
de- Acrylic nails are commonly used for
os- finger prostheses when the residual
ain finger length is not an issue and in
!SI6 most partial and full hand restora-
pli- tions; they are less commonly used in
.us- Figure 11 Samples of hair that can be used in prosthesis development . prostheses for lower limb restora-
tes- tions.
erings generally terminate at the knee.

Hair
process is completed, silicone cover-
ings are fitted over the prosthesis. For The colors of the foot, leg, hair, and Even if the color, shape, and texture
,nal transtibial coverings, the silicone ter- nails are incorporated into the pros- of the silicone skin are perfectly
eses minates at the proximal edges of the thesis so that the appearance in open- matched, prostheses for patients wit11
:ne- prosthetic socket (Figure 10). The toed footwear is natural. Increased moderate to dense body hair are not
1ore considerations relevant to elbow cov- forces and wear associated with walk- acceptable without an attempt to re-
nts, erings also apply to transfemoral cov- ing, coupled with the high cost of sil- produce tl1eir hair pattern. This is ac-
!nts erings as a continuous cover distorts icone manufactw·ing, lim it the appli- complished by painting the illusion of
s is during knee flexion and inhibits knee cations for this type of restoration for hair into the silicone, or by applying
tent motion. Therefore, transfemoral cov- lower limb amputees. synthetic or human hair into or onto

the skin in a pattern similar to that of experienced by individuals with limb l I. Burkhart A, Weitz J: Oncological ap-
the patient (Figure 11). loss. plications for silicone gel sheets in soft
t issue contractures. Am J Occup Ther
1990; 45:460-462.
Color Changes References 12. Ohmori S: Effectiveness of silastic
Human skin is dynamic, exhibiting I. Fraser CM: An evaluation of the use sheet coverage in the treatment of scar
made of cosmetic and functional pros- keloid. Plast Surg 1988;12:95-99.
cyclical color changes that may be
subtle or dramatic. These changes can theses by unilateral upper limb ampu- 13. Quinn KJ: Silicone gel in scar txeat-
tees. Prosthet Orthot Int 1998;22:216- ment. Burns 1987;13:533-540.
be internal and physiologic, such as
224. 14. Atki ns D: Adul t upper limb prosthetic
the changes caused by surface capil-
2. Hubbard S, Bush G, Naumann S: Myo- tra ining, i11 Bowker JH, Michael JW
lary dilation. Color cha11ges may also
electric prostheses for the limb- (eds): Atlas of Limb Prosthetics, ed 2. St.
be external ru1d environmental, such
deficien t child. PMR Clinics North Am Louis, MO, Mosby-Year Book, 1992,
as. suntanning. Unlike human skin,
1991;2:847 -866. pp 277-291.
silicone is static. When the silicone of
3. Hubba.rd SA, Kurtz I, Heim W, et al: 15. Bennett JB, Alexander CB: Amputa-
a prosthesis is pigmented, the color is
Powered prosthetic inter vention in t io n levels and surgical techniques, in
carefully matched to the colors of the upper extremity deficiency, in Herring Atkins DJ, Meier RH (eds): Compre-
amputee's skin at the time it is JA, Birch JG (eds): The Child With a hensive Management of the Upper Limb Ir
painted. Once applied, the color can- Limb Deficiency. Rosemont, IL, Ameri- Amputee. New York, NY, Springer-
not easily be changed. If the patien t's can Academy of Orthopaedic Su r- Verlag, 1990, pp 1- 10. Bil
ski n darkens significantly, the pros- geons, 1998, pp 417-431. 16. Cond ie DN, Stills M: Prosthetic and
pr,
thesis also needs to be darkened to 4. Kyberd PJ, Davey JJ, Dougall Morrison orthotic management, in Bowker JH, r o1
maintain an acceptable match. Michael JW (eds): Atlas of Limb Pros- Cal
J: A survey of upper- limb prosthesis
To solve this problem, the patient users in Oxfordshire. ]PO 1998;10: thetics, ed 2. St. Louis, MO, Mosby- WI
can o btain two devices that represent 85-91. Year Book, 1992, pp 403-412. otl
the extremes of lightness and dark- 5. Michael JW, Buckner H: Options for 17. Inman V, Ralston HJ, Todd F: Pros- en
ness typical of their skin color finger prostheses. ]PO 1994;6:10-19. thetics, in Rose J, Gamble JG (eds) : to
changes. Another option is to obtain a 6. Millstein SG, Heger H, Hunter GA: Human Walking, ed 2. Baltimore, MD, co:
prostl1esis that accepts a surface pig- Prosthetic use in adult upper limb Williams & Wilkins, 1994, pp 165- 199. pl.
ment, which is applied to deepen or amputees: A comparison of the body 18. Malone JM, Fleming LL, Roberson J, th.,
darken the color. Normal exposw·e to powered an d electrically powered et al: Immediate, early and late post- re1
ultraviolet light causes this smface prostheses. Prosthet Orthot Int 1986; l 0: surgical management of upper limb ev,
27-34. amputation. J Rehabil Res Dev 1984;21: an
pigment to fade to the original lighter
7. O'Farrell DA, Montella BJ, Babor JL, et 33-40. lat
shade.
al: Long-term follow-up of 50 Duke 19. Allison A, Mackin non SE: Evaluation W€
silicone prosthetic fingers. J Hand Surg of digital prostheses. J Hand Surg [Am} m
Conclusion 1996;2 l :696-700. 1992;17:923-926. pe
8. Pillet J, Mackin EJ: Aesthetic restora- 20. Beasley RW, de Beze GM: Prosthetic six
The role of aesthetics in prostlletic
tion, in Bowker JH, Michael JW (eds): rep lacements for the thumb. Hand se1
restoration should not be overlooked, Clin 1992;8:63-69.
Atlas ofLimb Prosthetics, ed 2. St. ao
especially when treating individuals Louis, MO, Mosby-Year Book, 1992, 21 . Manurangsee P, Isariyawut C, Chatu- su:
with upper limb deficiencies a11d pru·- pp 227-235. thong V, et al: Osseointegrated finger gr;
tial foot amp utations. The concept 9. Pilley MJ, Quinton DN: Digital pros- pTOstheses: An alternative method for
tllat prostlleses mimicking normal theses for single finger amputations. finge r reconstruction. J Hand Surg ti<:
appearance are somehow nonfunc- J Hand Surg 1999;24:539-541. {Am] 2000;25:86-92. pu
tional is obsolete. Aesthetic prostheses 10. Uellendahl J, Heelan J: Prosthetic 22. Herring HW, Romcrdale EH: Pros- ad
sho uld be provided whenever appro- management of the upper limb defi - thetic finger retention: A new ap- to
priate to address the intertwined cient child. Phys Med Rehabil 2000;14: proach. O&P 1983;37:28-30.
tic
functional and psychosocial deficits 221 -235.
Al
pl.
of
foi
er
so
tic
m,
te1

Bilateral Upper Limb Prostheses
;ar
tic
St.
in
rib Int roduction

Bilateral upper limb amputation is a person with a unilateral arm amputa- amputee. The treating or consulting
profound loss. Performi ng basic and tion, the person with bilateral upper professionals may include an ortho-
I, routine tasks such as eating and self limb amputations cannot compensate paedic surgeon, physiatrist, prosthe-
care becomes difficult or impossible for the inadequacies of a prosthesis tist, occupational therapist, physical
without assistance. Prostheses and with the use of an intact physiologic therapist, psychologist, nurse, and a
other assistive devices can enable us- arm. 1 Therefore, it is paramou11 t that social worker. An invaluable adjunct
ers to regain some of their lost ability every detail of prosthetic design be to the care and treatment provided by
to manipulate objects and successfully optimized. Given the current inability these professionals is patient access to
D, complete a wide variety of tasks. Re- to duplicate the diverse and complex peer support whenever available.
99. placing the many exquisite features of functions of the human arm, pros- Patient factors that affect pros-
J, the physiologic hand, however, is cur- thetic systems should be viewed as thetic component and con trol scheme
rently impossible. T he completion of tools, with each component being selection include cognitive level, me-
even simple manual tasks requires an best suited for certain uses. Success chanical aptitude, family life, occupa-
;21: amazing amount of complex manipu- relies on the selectio11 of the most ap- tion, hobbies, and self-image. Resid-
lation. These words, for example, propriate components for the desired ual limb length, and strength and
)11 were typed using 10 fingers working tasks, matching those components range of motion of the joints of the
\m] in concert. Each finger performs inde- with optimal control sources and in- upper limbs, including scapulotho-
pendent and sometimes coordinated terfacing them with the human body racic motion, should be carefully
c simultaneous functions, relying on in a comfortable and functional man- evaluated as these will have direct im-
sensation and precise positioning to ner. Of equal importance is the user's plications regarding the method of
accurately produce the intended re- dedication and motivation to succeed prosthetic fitting. The general
u- sult. These abilities are taken for in the face of adversity. strength and flexibility of the lower
er granted until they are lost. limbs should be assessed as well. With
For The goal of prosthetic rehabilita- more proximal amputations, foot use
tion for the bilateral upper limb am- Patient Evaluation should be encouraged, with training
putee is to enable the individual to Given the complexity of bilateral up- dedicated to exploring and develop-
achieve fw1etional independence and per limb loss and the fluid nature of ing the manipulative capabilit ies of
to participate successfully in voca- the early rehabilitation period, thor- the feet (Figure 1). At the concl usion
tional as well as recreational pursu.its. ough evaluation of the new bilateral of the initial evaluation process, a de-
Although bilateral prosthetic arm re- upper limb amputee should occur fined plan for the selection of the
placement offers only a small amount over a period of time. Most often, pa- prosthetic components and control
of the functions lost, users can per- tients who sustain bilateral upper scheme should be in place. However,
form many activities that would oth- limb amputations have experienced a the team needs to be flexible through-
erwise be impossible. Subtle details of traumatic injury, so there are medical out the rehabilitation process. The
socket fit, control system configura- issues in addition to limb loss. Ideally, configuration of the prosthesis will
tion, and suspension can sometimes a team of experienced professionals almost inevitably evolve in response
mean the difference between long- should be working in concert to ad- to the changing needs and abilities of
term success and failure. Unlike the dress the many issues faci ng the new the user. Such changes can be ex-

jects that differ in size, shape, and tex- th

ture. Information about the charac- d,
teristics of an object would be relayed pt
to the user through a sensory feed- li!
back system. Proprioception regard- fa
ing the speed of prosthetic move- pl
ment, the force exerted, and the ec
position of the prosthetic device hf
would be inherent. The hand would ti<
be lightweight and durable. Cunently in
available state-of-the-art prosthetic of
prehensors are far from this ideal. ce
Figure 1 A, Persons with congenital bilateral upper limb deficiency often develop re·
markable dexterity and manipulative foot function. B, Adults with acquired bilateral up· Available technology can be opti- fu
per limb loss usually do not develop this kind of foot function but may find foot use an mized, however, by considering the aJ
efficient alternative to prosthetic function for tasks away from the body. (Reproduced needs of each individual and then w.
with permission from Fenstermacher Photo Release.) comparing the attributes of each in
prosthetic component and control th
scheme to the ideal. pc
Although this chapter focuses pri- la-
marily on the management of adult b,
amputees, many of the concepts pre- is
sented have application for the man- PI
agement of children. Pediatric pa- si1
tients, however, cannot be treated tii
simply as small ad ults because of their pt
small size and sometimes immature pt
cognitive ability. With a small body C(
size comes decreased physical ability SC
to generate useful force and excw-sion to
and a lower tolerance for weight and tii
prosthesis complexity. Congenital bi- ";g
lateral limb deficiency is very rare, c,e
and the issues regarding prosthetic di)
Figure 3 A young boy with acquired bi- fitting for children with this defi- Ii,
lateral very short transhumeral amputa· ciency can be quite different from vi
tions demonstrates the superior manipu· those of adult bilateral upper limb se
lative function provided by his sensate amputees (Figure 2). On the positive cc
feet, as he stabilizes the object with his
prosthesis.
side, children with congenital limb bE
Figure 2 This teenage boy with congeni- deficiency are often much more it~
tal quadrimembral limb deficiency dem· adaptable than adults and will do re-
onstrates the use of his prototype pros·
thesis. The control scheme provides
consider the advantages and disad- markable things with their residual th
dedicated variable-speed control of the vantages of various components and limbs and their feet 2 (Figure 3). The llj
hand, wrist, and elbow using two-site control options for a specific individ- section 011 pediatric issues provides dt
myoelectric control of the hand, a linear ual. To give structure to this thought more detail about this unique cohort A:
transducer for elbow operation con - process, it is useful to understand the as
of patients.
trolled by scapular abduction, and a pair
attributes of the "ideal" prosthesis Ii,
of FSRs positioned near his mobile right
acromion for wrist rotation. (Reproduced and then compare these attributes to s:i:
with permission from Gentry Photo Re- existing technologies. The ideal pros- Staging of Care le.
lease.) thesis would fully restore the appear- A prosthesis should be fit as soon as pl
ance and function of the limbs lost. possible, preferably within the first 30 w
Considering prosthetic prehensors, to 90 days, for all patients with either tic
pected and are considered part of the this would mean that the ideal pre- unilateral or bilateral acquired arm to
normal recovery process from such a hensor would be a hand. Con trol of amputation. The fU'St 30 days after le
massive functional loss. the hand would be subconscious and amputation have been referred to by cc
Throughout the evaluation pro- natural. The hand would be capable Malone and associates 3 as the golden th
cess, the prosthetist should carefully of manipulating a wide variety of ob- period of fitting for upper limb pros- to

Chapter 25: Bilater al Upper Limb Prostheses 313
c- thetic devices, based on clinical evi- the prototype prosthesis, as will be

dence that optimal acceptance and discussed later in this chapter. The
:d practical use of a prosthesis are most prototype prosthesis allows the am-
i- likely to occur during this period. putee and the team to evaluate vari-
i- Early postoperative fitting has multi- ous prosthetic systems before decid-
e- ple advantages, including decreased ing on a definitive prescription.
1e edema and pain, accelerated wound Short-term goals will generally focus
ce healing, improved patient rehabilita- on mastering basic daily functional
ld tion, decreased length of hospital stay, use of the prostheses for tasks such as
ly increased prosthetic use, maintenance donning, eating, and toileting. Long-
jc of some continuous type of proprio- term goals may include dressing,
al. ception input through the residual vocational skills, and avocational pur-
ti- limb, and improved psychological .ad- suits. During this period of experi-
he aptation to amputation. In patients mentation, the amputee should spend
en who have injmies or other complicat- most of his or her tinle at home, peri-
ch ing factors that make fitting within odically returning to the rehabilfra-
:ol the golden period impractical or im- tion facility for prosthetic modifica-
possible, prosthetic use may be de- tions and additional training. Jn this Figure 4 The functional envelope can
ri- layed. In many patients, one side may way, the user will be better able to de- sometimes be expanded by repositioning
ult be ready to fit before the other, and it termine which prosthetic systems the prosthesis on the limb to produce
re- is advisable to do so. Indeed, initially work best in a real-life situation and more useful function. This man demon-
m- providing a prosthesis on only one to identify specific problems that strates retrievi ng his wallet from his back
pocket, requiring· hook operation behind
>a- side is often desirable. For most pa- need attention during the next visit his back.
:ed tients with bilateral upper limb am- with the team.
eir putations, it is beneficial to begiJ1 Complete independence is ex-
Jre prosthetic training using a simplified pected to be achieved in all patients sion system so that the prosthesis feels
,dy component configuration and control except those who have lost both limbs firmly connected to the user under
lity scheme as this is easier for the patient above the elbow or who have other conditions of dynamic use. This inti-
ion to master initially. Especially for pa- limiting factors. Strongly motivated mate fit will not only provide optimal
md tients with higher level amputations, bilateral transhumeral amputees can control of the positioning of the pros-
bi- "gadget overload" is a practical con- sometimes attain complete indepen- thesis but will also minimize the sen-
tre, cern, as each limb may have multiple dence in accomplishing their daily sation of weight. T he socket is the
!tic dynamically positioned components. regimen, but realizing this goal can foundation of the prosthetic system,
efi- In these situations, it is generally ad- take an extended period of time. and any shortcomings iJ1 socket de-
om visable to introduce new components sign will adversely affect the success
mb sequentially to allow the user to ibe- of the prosthesis. This is true for both
tive come accustomed to each new device
Socket Design body-powered and electronic control
rob before increasing the overall complex- Socket designs for bilateral amputees systems. There should be minimal
.ore ity of the artificial limbs. do not differ substantially from those lost motion, so that as the residual
re- Given the dynamic nature of pros- for unilateral amputees, except that it limb begins to move, the prosthesis
lual thetic rehabilitation of the bilateral is even more crucial to permit as responds immediately.
fhe upper limb amputee, it is useful to much range of motion as practical. TransradiaJ amputees using body-
ides develop short- and long-term goals. Because of the absence of both hands, powered control will most often ben-
1ort As the amputee's skills develop, and however, it is important to consider efit from flexible hinges as these com-
as his or her medical condition stabi- ease of donning and flexibility in po- ponents allow them to retain active ,'.
lizes, ru1d priorities change in re- sitioniJ1g of the prostheses. Position- use of physiologic forearm rotation.
sponse to the realities of the chal- ing flexibility includes range of mo- In patients with significant remaining
lenges of daily life, so too, the tion of the int.act physiologic joints forearm rotation, it is critical that the
11 as prosthetic devices and use pattern with the prostheses donned , and, in socket shape capture the maximum
t 30 will change. The process of rehabilita- some patients, the ability to reposi- amount of available motion. Supra-
ther tion can be expected to take 6 months tion the prosthesis at the limb-socket condylar socket designs do not allow
arm to 1 year or more, depending on the interface in a manner that increases physiologic forearm rotation, so this
1fter level of linlb loss, the extent of other functionality (Figure 4). Although the important disadvantage must be con-
) by complicating factors, and how quickly socket may not always be completely sidered carefully. Self-suspending
lden the amputee adapts. An invaluable self-suspending, the interface should sockets such as those typically used
,ros- tool dming this period of change is fit snugly and work with the suspen- for myoelectric control, and to a

preferred because they allow relatively trolled myoelect.rically, it may be ad-

free range of motion at tl1e shoulder vantageous to allow the shoulder to
joint, especially when sufficient limb move independently of tl1e frame to
length r emains. Another option for prevent movement of the electrodes
socket design is the half-and-half on the skin, resulting in loss of con-
socket described by Sauter. This trol. Shoulder motion can often be
socket uses a flexible silicone proxi- used to activate various electronic in-
mal section that is fitted over the puts. In this configuration, the weight
shoulder region and is fabr icated as of the prosthesis anchors the frame to
a n integral part of the socket. The the user, whereas the shoulder is free
deltoid area is cut out laterally to im- to move independently. Several shoul-
prove flexibility and air circulation der clisarticulation frame variations
within the socket. The socket is rigid are in use today. When designing a
distally from the axilla level7 (Figure frame for an inclividual, the prosthe-
5). This design works particularly well tist should consider control sources,
Fig
Figure 5 The half-and-half socket pro- with a completely myoelectric pros- harness attachments, and mounting sor
vides an integral shoulder saddle offering thesis, in which case the only function of the mechanical shoulder joint
good suspension and comfort. Use of a of the harness is to hold the silicone mechanism, in adclition to the above-
passive prosthesis on one side is some- piece in place on the shoulder. An- mentioned design objectives. These fit1
t imes indicated when no functiona l pros- a!
other option similar to the half-and- design requirements will dictate the
thesis is desired. Here t he passive pros-
thesis provides a firm anchor point for half socket is the flexible shoulder optimal frame geometry for each pre
the harness of the contralateral prosthe- suspension system in which a strip of prosthesis. int
sis and provides a more normal appear- Lycra-backed neoprene or sim ilar ma- lat
ance for t his amputee with a very short terial replaces the silicone saddle and soc
rig ht t ranshumeral amputation and a left
is attached to the wings of the stan-
Harnessing an
interscapulothoracic amputation.
dard open shot1lder socket. 1 Closed Conventional harnessing serves tl1e the
shoulder designs are best used for dual role of suspension and control of be
lesser extent, for body-position con- short residual limbs when there is in- the body-powered prosthesis. In de- ill(
trol, are generally best donned by sufficient leverage to use the foll signing a harness system for the bilat- bil
pushing the residual limb into the range of physiologic shoulder mo- eral upper limb amputee, it may be bo
socket because of the obvious diffi- tion. The closed shoulder socket of- useful to consider suspension and tee
culty of pulling in with a stockinette. fers good stabilization of the prosthe- control separately. When electrically ne
The Northwestern University self- sis on the user and a convenient and powered components are used, or th,
suspending socket4 offers particular sec1u·e anchor point for the harness when the socket design provides sus- th,
advantages for bilateral transraclial lateral suspension strap. pension, the harness requirements are an
fittings in which supracondylar sus- The design of a shoulder clisarticu~ altered. Cognizance of these factors Ull
pension is desired because it tends to lation interface requires sufficient can result in simpler, less restrictive lat
offer good range of motion at the el- surface area to effectively stabilize the harness designs and ultimately a pros- Joe
bow and is easily donned by pushing prosthesis on the amputee. Because of thesis that is more comfortable to co
in. The Northwestern socket can also the length of the prosthesis lever arm wear. In situations in which right and W(
be modified with a cutout over the and the weight of the components, left prostheses are harnessed together, an
olecranon, which reduces heat there is a strong tendency for rotation each prosthesis serves as the anchor pe
buildup and improves cosmesis, espe- at the prosthesis-user interface, espe- point for the o ther. This design has ad- co
cially when the elbow is extended.5 cially as the terminal device is moved vantages but can sometimes lead to indi:
On rare occasions when pulling in is away from the body. Therefore, the advertent activation of the opposite
deemed necessary, a nylon donning socket perimeter should extend suffi- limb (sometimes referred to as cross- ht
bag is an effective tool and can be ciently onto the torso to resist these control) in fully body-powered sys- pc
used independently by some patien ts. forces. The use of a frame-type socket tems. One solution would be to pro- a
Sockets for the transhumeral pros- will allow the requisite stabilization, vide a fully body-powered prosthesis sic
thesis should also provide a close cou- facilitate heat dissipation, and mini- on one side and a fully electronic pros- ha
pling of the residual limb and the mize weight. If body-powered control thesis on the other. In this situation, an
prosthesis to maximize prosthetic is used, the frame should capture as the difference in control methods th
function. Ideally, the socket design much body motion as possible, par- makes it much easier for the amputee Ei
should cause little or no restriction of ticularly biscapular abduction. Any to control the arms independently. a
motion at the next proximal joint. loss of motion will limit prosthetic ln some patients with bilateral up- SU
Therefore, open shoulder designs6 are function. If the components are con- per limb amputations, a socket may be th

Chapter 25: Bilateral Upper Limb Prostheses 315
i-
to
to
es
11-
)e
n-
ht
to
ee
11- Figure 7 A leather pad can be provided
ns to replace the cross point of the webbing
harness, t hereby spreading the load over
a
a larger area and helping to position the
Le- control attachment straps lower on the
es, back for great er excursion.
Figure 6 A shoulder cap can be provided on the interscapulothoracic side for the per-
ng son w it h interscapulot horacidtranshumeral amputations.
lnt
re-
~Se fitted for the sole purpose of providing the control attachment straps more
:he a secure anchor for the contralateral inferiorly on the scapulae, thereby in-
1ch prosthesis. One example is the creasing the available excursion (Fig-
interscapulothoracic/transhumeral bi- ure 7). Another useful modification is
lateral design in which a frame-type the cross-back strap, which also keeps
socket or shoulder cap provides a firm the control attachment straps low on
anchor for suspension and control of the scapulae. A double-ring harness
the the transhumeral prosthesis and can offers another option to accomplish
I of be shaped to provide shoulder sym- this result (Figure 8). Harness config-
de- metry under clothing (Figure 6) . The urations for bilateral fittings in pa-
lat- bilateral transradial amputee using tients with differing amputation levels
be body-powered control is generally fit- require careful planning and customi-
md ted with a standard figure-of-8 har- zation to provide optimal stabiliza-
:tlly ness, typically incorporating a ring at tion, suspension, and control. Figure
or the cross point for free movement of 9 shows examples of successful har-
.us- the straps, along with flexible hinges ness designs for patients with asym-
are and a triceps pad. Compared with the metric limb loss.
:ors unilateral figure-of-8 harness, the bi- Figure 8 The double-ring harness in-
creases available excursion by positioning
tive lateral version eliminates the axilla
:os- loop, which is a frequen t area of dis-
Components the contro l attachment straps lower on
the scapulae, as seen in this t rans-
to comfort. Thus, the bilateral harness is Terminal Devices humeral/transradial example.
and well tolerated by almost all patients The new bilateral upper limb ampu-
her, and is also easy to don and doff inde- tee is likely to prefer to be fitted with
maintained without significant exer-
hor pendently. Bilateral myoelectricaJly prosthetic hands, an intuitive choice
ad- tion, but their control systems offer lit-
controlled prostl1eses at the transra- given the societal expectation that
' in- tle direct proprioceptive feedback. 8 If
dial level typically require no harness. available technology can replace the
>site Similarly, the bilateral trans- function and appearance of the phys- having an anthropomorphic appear-
oss- humeral amputee wearing body- ance is critical to the patient, then at
iologic hand. The rehabilitation team
sys- powered systems is usually fitted with must gently educate the patient and least one electrically powered hand is
)rO· a figure-of-8 harness. If cable exc1u - family so both come to realize that generally warranted.
tesis sion is limited, it is advisable to use a the current state of the art is not this Cable-driven grippers, such as the
ros- harness design without a ring to limit versatile. Most body-powered hands split hook, offer direct proprioception
·i on, any loss of motion that occurs when are mechanically inefficient, offer lit- via the cable and harness system.
1ods the harness straps rotate on the riing. tle grip force, and have proved to be Component movement and forces are
utee Either a standaxd sewn cross point or of very limited functional use. sensed by the controll ing body part
r· a leather pad may be beneficial in Compared with body-powered when the harness compresses the un-
up- such situations. The leather pad has hands, electrically powered prehensors derlying skin,8 as will be discussed in
tybe the additional advantage of ro uting offer a much tighter grip that can be detail later in this chapter.

Fi~
ior
un
sic
blE
Figure 9 A, An example of a harness for shoulder disarticulation/transhumeral combination in which t he transhumeral prosthesis is en- vie
t irely body powered and th e hybrid shoulder disart iculation prosthesis uses myoelectric control of the terminal device and body-
powered control of the elbow. A single anterior chest strap allows independent donning and doffing. B, A simple fig ure-of-8 ring har-
ness can be used for t he transhumeral/transradial amputee if sufficient excursio n is available. C, In sit uations in which excursion is fle
limit ed, a sewn cross-point and a cross-back strap are usually advisable to maximize excursion. de
ro
Bilateral electronic hands and grip- natural appearance of the body- able in a wide variety of shapes, sizes, en
pers have been most successful in pa- powered hook. and specific prehension patterns. ca
tients with transradial or wrist disar- For bilateral fittings, it is generally Voluntary-closing hooks are less com- ra:
ticulations. An electrically powered advisable to use two different types of monly used by bilateral amputees even be
device provides prehension forces prehensors to provide greater grasp though body-powered voluntary- joi
three to six times the force possible versatility. One common strategy is to closing hooks offer both excellent tr<
with the typical voluntary-opening provide a hook with canted fingers on feedback regarding prebension forces he
split hook, making the grip more se- the dominant side and a lyre-shaped and good grip strength. Requisite con- ro
cure for bilateral users. 1 As electronic hook on the opposite side. The canted tinuous cable tension or the need for a ne
hands and the means of controlling hook allows good visual feedback of locking mechanism to mai11tain grasp, Cc
them gradually improve, their utility objects being manipulated, and the as well as the limited number of design fu
for the bilateral amputee should be lyre-shaped hook provides better sta- configurations for voluntary-closing in:
continually reevaluated. At present, bility for gripping large cylindrical ob- hooks, appears to restrict the use of
few persons with bilateral amputa- jects. Another clinically successful ter- voluntary-closing hooks. us
tions choose hand-like prehension de- minal device combination is a canted Task-specific terminal devices si~
vices for long-term use, despite the hook on the dominant side and an should always be considered for the hi:
strong preference expressed for such electrically powered prehensor on the bilateral amputee. These devices are to
devices at the initial fitting. Anthropo- other side. This combination provides generally used with quick-disconnect fri
morphic devices are bulky and ob- the fine manipulation capabilities of a wrist components to facilitate inter- m·
struct the view of the object being split hook with the superior gripping change between a utilitarian hook d11
grasped. In my e.>.'Perience, most users forces of an electronic prehensor. In and specific-use devices such as work it
prefer body-powered split hooks for my experience, this combination has tools and kitchen utensils. One inno-
dominant side function. The slender been particularly weU accepted by the vative approach uses a hands-free tool th.
fingers of the split hook allow rela- transhumeral/shoulder disarticulation exchanger that permits automatic re- bo
tively good visual access to the work amputee. lease and exchauge of one task- de
area and the objects being handled. As Voluntary-opening hooks are used specific device for another. wi
the person with bilateral acquired am- primarily for bilateral amputees be- W<
putations gradually comes to terms cause these components maintain Wrists fo
with the magnitude of loss and his or grip without requiring the amputee to Wrist flexion is particularly helpful n.a
\V(
her altered self-image, practical con- generate constant cable tension. An- for body-centered activities, such as
siderations such as ease of use for fine other reason that these hooks are feeding, d ressing, oral and facial hy- be
grasping tasks often outweigh the un- commonly used is that they are avail- giene, and toileting. Therefore, wrist ra,

Figure 11 M idforearm f lexion facil itates

hook placement for midline activit ies
when elbow range of motion is limited.
Figure 10 The four-function forearm setup allows body-powered control of wrist f lex-
ion and rotation. A, The wrist flexion lock is actuated by pulling against the knee; t he vice, which improves the ease of mid-
unlocked w rist is flexed by pulling on the control cable and extended by an elastic ten-
line tasks. A greater amount of cable
sion band. B, Wrist rotation is unlocked by depressing a lock lever against the torso; ca -
ble tension causes the unlocked wrist to supinate t he terminal device; pronation is pro· excursion is required in the flexed po-
,en- vided by an internally mounted coil spring. sition, depending on the cable system
ody- configuration (Figure 11).
har-
,n is tlexion should be provided on the disarticulation amputees. Elbows
dominant side, if not bilaterally. Wrist In my experience, the preferred Selection of the most appropriate el-
rotation is essential for effective ori- system for transhurneral amputation bow should include careful evaluation
izes, entation of the prehension device. If a and shoulder disarticulation patients of weight, control options, and com-
:rns. cable-actuated prehensor is used, the is the body-powered system based on patibility with the other desired com-
om· range of wrist rotation will be limited this four-function forearm setup;9 ponents. Body-powered elbows are
even because the control cable crosses the this system uses a common control lighter and faster than electrically
ary- joint. The combination of an elec- cable to position four different body- powered units, but they provide very
llent tronic rotator and an electronic pre- powered prosthetic components: little live lift. Electrically powered el-
>rces hension device does not limit wrist (1) split hook, (2) wrist tlexion unit, bows have greater lifting capacity but
con- rotation because no control cable is (3) wrist rotation unit, and ( 4) elbow. are heavier and lack the propriocep-
for a needed to activate the prehensor. 1 The simplicity of the control method tive feedback inherent in the cable
rasp, Continuous wrist rotation can be use- is a mixed blessing. An advantage of control of body-powered elbows. 1
!Sign ful for certain activities such as turn- this method is that the same physio- A spring lift assist or automatic
)Sing ing a water spigot. logic control motion is used to posi- forearm balance should be considered
,e of Locking wrist components are tion each of the four components, for all body-powered elbow fittings.
usually more useful than friction de- th us conserving available control These devices allow the prosthetist to
vices signs. Bilateral amputees must apply sources. The control arrangement, optimize and balance the force/
r the high forces through their prostheses however, is sequential in that only one excursion requirements with the abil-
s are to accomplish various tasks. When device can be positioned at a time. ities and needs of a particular user.
meet friction devices are used, the friction Therefore, it is not possible to pro- In bilateral amputees who require
nter- must be very strong for it to be stable duce coordinated movements involv- two elbows, it is sometimes beneficial
hook during these tasks, which then makes ing two or more components. The to provide one body-powered type
work it difficult to reposition the device. straightforward method of control and one electrically powered type.
.nno- Positive-locking componen ts make and the inherent proprioceptive feed- The two elbows complement each
! tool the prosthesis a rigid extension of the back appear to outweigh these disad- other as the electrically powered side
ic re- body that can maintain position un- vantages for most users. 1 offers greater live lift capacity and the
task- der high loads and yet be repositioned Midforearm flexion offers a body-powered elbow makes precise
with ease when unlocked. One note- nonanthropomorphic solution to positioning easier. 1
worthy body-powered system is the limited range of motion and has been Rigid elbow hinges are rarely ap-
four-function forearm setup origi- particularly useful for the short or propriate for bilateral transradial am-
elpfu1 nally described by Robinson and Cay- very short transradial amputee. By putees because these hinges prohibit
ch as wood (Figure 10). This system has placing the flexion device more prox- active pronation and supination. One
11 hy- been used successfully by short trans- imal in the prosthesis, a greater arc of exception is the step-up hinge that re-
wrist radial, transhumeral, and shoulder motion is achieved at the terminal de- quires twice the force for motion but

Figure 12 A fair-lead cable can be used

to assist elbow flexion so long as suffi-
cient extension force can be generated to
stabilize t he elbow during hook opera-
tion.
Figure 13 Locking humeral rotation

moves the forearm 2° for every 1° of makes it simple to move t he terminal de-
vice transversely yet provides a rigid limb
residual limb flexion. The disadvan-
to resist high forces when locked. This bi-
tages of the step-up hinge include Fig
lateral shoulder disart iculation amputee
poor forearm cosmesis when the el- by
demonstrates the ability to bring his ter-
minal devices into contact with each
vid
bow is flexed, the extent of which is Figure 14 A locking shoulder joint allows the
dependent on the length of the resid- other, allowing bimanual manipulation. this bilateral shoulder disarticulation am-
(Reproduced with permission from Fen- she
ual limb. The disadvantages of this putee to operate the terminal device du,
stermacher Photo Release.) overhead. This terminal device is con-
specialized elbow joint are sometimes Ph<
trolled by a linear transducer using shoul-
outweighed by the increased range of der elevation, providing reliable variable-
motion afforded. A fair-lead cable tator designed to interface with the speed control. (Reproduced with permis-
T
housing also can be used with these ubiquitous Hosmer Dorrance E-400 sion from Fenstermacher Photo Release.)
hinges to supplement elbow flexion mechanical elbow (Hosmer Dorrance,
p
force as long as the user has sufficient Campbell, CA), although it is possible operate the terminal device overhead F,
elbow extension force to stabilize the to adapt this rotator for other elbows, is invaluable, as it increases the scope G
forearm during operation of the ter- including electronic ones. 1• 10 The lock of practical work that can be accom- S·
minal device. This same cabling is operated by a control cable that can plished with the artificial arm (Figure c
method using standard single-pivot be actuated through a harness strap 14).
hinges can be advantageous for the that is parallel with the elbow Jock
user who has weak elbow flexor control strap or by a chin-actuated
strength on presentation, as long as nudge control (Figure 13). Prosthesis Control
s
an adequate range of passive flexion The two basic categories of currently c
range is available and there is enough Shoulder Joints
available prosthetic controls are body
extension force to resist further flex- The bilateral amputee who requires a position control and myoelectric con- "c
ion during operation of the terminal prosthetic shoulder joint will benefit trol. Body position control refers to (
device (Figure 12). from a device that locks in position for voluntary movement of anatomic c
the same reasons as those described structures and the excursion and/or
Humeral Rotation for locking wrist and humeral compo- forces produced by those motions
All internal locking elbow systems nents. The LTI-Collier joint (Liberat- (Table 1). Cable-operated compo-
routinely used in North America, ing Technologies Inc, Holliston, MA)
wt
nents are the most common examples
provides a positive locking feature for to
whether body-powered or electrically of this type of control, but body mo-
powered, include a mechanism simu- flexion-extension as well as friction for tions a.re also useful to operate elec-
lating passive humeral rotation that is abduction control. This joint locks at tronic inputs such as switches, servos,
lCc
stabilized by friction. Locking hu- 10° intervals. The lock can be operated and pressure transducers (Figure 15).
meral rotation may be beneficial for either by a cable n udge control or with Myoelectric control uses the electrical be
an electronic actuator. The rigidity of th,
bilateral fittings and for selected w1i- by-product of voluntary muscle con-
lateral arm amputees, offering the the locked shoulder joint allows the tractions, as discussed in chapter 12. so
same relative advantages as a locking person to use the prosthesis more ef- Unlike many cable con trol systems, Cc
fectively as an extension of the body. 1 myoelectric control is generally inde- 011
wrist unit. Rimjet Corporation (Sara-
sota, FL) offers a locking humeral ro- For bilateral amputees, the ability to pendent of proximal joint position,

Figure 16 This patient has quadrimembral amputations plus paraplegia. He uses a sin-
gle multifunctional prosthesis to achieve partial independence in self-feeding and ma-
nipulation of simple objects. A, The wrist rotator, positioned at midforearm, is con-
trolled by a rocker switch using his chin. The wheelchair-mounted bracket assists with
internal and external rotation of the humeral turntable. Wrist flexion is achieved using
a conventional flexion wrist. B, An electronic elbow is operated with a pair of FSRs
Figure 15 A linear transducer activated mounted anteriorly and posteriorly within the socket, and the terminal device is con-
by contralateral scapular abduction pro- trolled using scapular abduction and a harness pull switch. Coordinated elbow flexion
vides variable-speed control of the pros- and wrist rotation are possible and are useful for self-feed ing.
lows thetic elbow for this boy with bilateral
am- shoulder-level limb deficiencies. (Repro-
!Vice duced with permission from Gentry
and control options will facilitate the allows immediate use of each compo-
con- Photo Release.) intended function of ilie user. nent and, sometimes, results in sinml-
1oul- For the bilateral amputee, the reli- taneous control of two components
ible-
ability of the control system is of par- for the production of coordinated
'mis-
TABLE 1 Body Position Control amount importance. A control source movements. 1•8 The use of a body-
1se.) Sources
is reliable only when each and every powered elbow and myoelectric hand,
Primary Work Sources Producing Good control command results in the defor example, allows the amp utee to
1ead Force and Excursion sired component function. In addi- reach out and open the terminal de-
cope Glenohumeral flexion tion, a component should never oper- vice in one fluid motion, similar to
:om- Scapular/biscapular abduction ate inadvertently. Whenever a control the function of the natural arm.
gure Control sources for mechanical locks command fails to produce the desired For bilateral fittings, dedicated
and electronic inputs
result, the overall utility of the pros- control is always preferable. For am-
Glenoh umeral
extension/abduction/shoulder thesis is severely compromised. putations at higher levels, achieving
depression Therefore, control systems that are dedicated control poses a significant
Shoulder elevation overly complicated or that rely on a challenge because of ilie increased
ently Chest expansion marginal control source are rarely number of potential prosthetic joints
body Abdominal expansion successful for long-term use. Training and the limited number of available
con- Chin nudge for prosthetic use is often essential in control sources. It may be necessary
rs to Glenohumeral adduction ma>.imizing the reliability of prosthe- to combine sequential and dedicated
omic Other (any movable body part) sis control. However, if training fails controls to provide all of the desired
1d/or to produce consistently reliable con- functions. In these complex situa-
,tions trol function, then an alternative con- tions, component functions should be
mpo- trol method is indicated. prioritized, and those that are fre-
which can make the prosthesis easier
nples In the context of operation of mul- quently needed or are interrelated
to use. should be assigned separate control
• mo- tiple components, control options are
When developing a prescription described as either dedicated or se- sources (Figure 16).
elec-
!!VOS,
for the upper limb amputee, it is crit- quential. Sequential control means
e 15). ical to understand the relationship that two or more components are Body-Powered Control
:trical between available control sources and controlled from a common source, Cable actuation of body-powered
: con- the types of components these making simultaneous control impos- prostheses provides users with a
er 12. sources can most effectively control. sible. Dedicated control assigns sepa- wealth of proprioceptive feedback
;tems, Component selection should be based rate control sources to each prosthetic through the physiologic joints har-
inde- on a careful analysis of which devices component. Although it is a more nessed to the prosthetic compo-
;ition, complex approach, dedicated control nents. 11 Users of these devices can

that this type of control is superior to sociated with grasp and release. The sirn
on-off and proportional velocity con- transhumeral amputee could there- po,
trol. Body-powered control of an el- fore use the biceps to close the hand effc
bow is very graceful, the rate of mo- and tlle triceps to open the hand be- sin:
tion is nearly normal, and positioning cause of a flexion pattern closely asso- exc
of the prehensor in space is very accu- ciated with grasping and an extensor wit
rate. Body-powered control of a pros- pattern associated with releasing. 8 due
thetic elbow can become subcon- Childress 12 described this as the myo- dri-
scious, as illustrated when the bilateral prehension principle, suggesting tllat tha
t ranshumeral amputee gestures with myoelectric control is more intuitive poi
his limbs, gracefully flexing and ex- for the amputee. As noted, a major
Figure 17 Biscapular abduction using a tending his mechanical elbows as he disadvantage of all myoelectric sys- Fo
linear transducer provides elbow control speaks. tems is the lack of direct feedback Cc
for t his patient with a bilateral humeral Cable efficiency is critically impor- from the control system regarding the Fo1
neck amputation. In t his patient, only tant to the success of many body- position, velocity, and force of the
one side is f itted with a prosthesis. The ver
powered fittings, particularly for pa- component. Thus, users of a myoelec- pla
contralateral side provides a suspension
anchor point and a valuable control tients with high-level amputations. trically controlled system must rely the
source for body motion control. Careful attention should be devoted primarily on visual feedback as they the
to producing the straightest line of manipulate their environment using sor
pull and to using materials that offer the prosthesis.8 the
readily perceive the position and speed the least amount of frictional loss, USf
of movement of the prosthetic com- such as a Spectra cable in a Teflon- Switch Control
ponents.1 Body-powered cable- in
lined housing.17 Switches are the most simple and ba-
operated devices offer many of the de- sic input devices for activation of
sirable characteristics of the control Myoelectric Control arr
electronic components. A variety of
theory proposed by Childress, 12 based the
The most physiologically natural switches has been used for prosthesis
on the work of Simpson, 13 which loa
metl1od of controlling an electronic control, including pull, push, rocker,
states: "The most natural and most the
hand is through myoelectric control. and toggle designs. Most switches
110
subconscious control of a prosthesis Myoelectric control looks very natu- provide only single-speed control
can be achieved through use of the the
ral because the muscle activity is in- and, therefore, are not optimally
body's own joints as control inputs in tio
side the socket and is invisible, in suited for terminal device operation
which joint position corresponds (al- hiE
contrast to control methods that re- or elbow or wrist rotation. Switches
ways in a one-to-one relationship) to on
quire body motions of more proximal are best used for lock activation and
CO i
prosthesis position, joint velocity cor- body segments.8 The most physiolog- mode selection when using a sequen-
responds to prosthesis velocity, and act
ically natural and inconspicuous con- tial control scheme. Simple switches
joint force corresponds to prosthesis an,
trol is achieved by the transradial am- are also used to turn power on and
force!' fot
putee by using myoelectric signals off, which is especially useful in situa-
This type of control is referred to (el
from the forearm flexors to close the tions in which the standard power
as extended physiological propriocep- ne:
hand and signals from the extensors switch for a particular component is
tion (EPP). Although implementation pin
to open it. When tlle transradial inconveniently located or inaccessible
of EPP control is possible with elec- socket is self-suspending, tlle harness to the bilateral amputee. th1
tronic components, 11 • 14• 16 it requires m,
can be eliminated. This results in a
fast, high-performance components greater range of functjon than with a Servo Control en
to produce optimal results. Presently, cable-driven terminal device because Servo control may be thought of as a on
EPP control is not commercially t he position of the prosthesis and op- more sophisticated type of switch exi
available, and available elbow compo- eration of the terminal device are not control in which the speed of the the
nents do not offer the required per- restricted by harness straps. prosthetic component is variable and OU
formance. More proximal muscles can also be is controlled by small body motions, pr,
Given the inherent feedback pro- used effectively for grasp and release usually through a harness system op
vided by the cable and harness system, control. Flexor-extensor patterns are (Figure 17). Servo controllers can use lat
body-powered elbow control is more associated with grasp and release. Al- either position or force as the input att
useful than any cmrently available though persons with higher level am- signal. A position servo has a trans·
electric control when adequate force putations cannot use the actual mus- ducer at the harness that measures ex· p
and excursion exist. Childress 12 and cle groups directly responsible for cursion. This excursion information
Doubler and Childress 14 conducted hand function, they can use remnant is then electronically processed and Be
tracking studies to provide evidence muscle patterns that are normally as- actuates the electronic component, pc

1e similar to the operation of a body-

e- powered system but requiring far less
td effort. A force-activated servo is quite
e- similar to a position-controlled servo,
)- except that no excursion is required
:>r with a force-activa ted servo. A trans-
,.'8 ducer measures the force applied and
)- drives the electronic component so
at that the speed of movement is pro-
ve portional to that applied force. 8
Figure 18 For this bilateral humeral neck
or
Force Sensing Resistor amputee, a mobile residual humeru s pro-
'S - vides excellent control of the electronic
ek Control terminal device using a pair of FSRs.
he Force Sensing Resistors (FSRs) are
be very thin input devices that can. be
:c-
upper limb amputee, it is often advis-
placed either inside the socket, where
:ly able to set up a clinical trial of the
the residual limb may press against
.e y proposed design using a prototype
them, or outside of the prosthesis, so Figure 19 Prototype prostheses are an
ng prosthesis. For the patient with a
some other body part might act on invaluable tool in the development of an
high-level arm amputation, this trial optimal prosthesis. The well-fitted socket
them (Figure 18). FSRs are typically
period can be critical to the long-term serves as the foundation for the proto·
used to provide proportional control type arm, and modular construction al-
outcome of prosthetic rehabilitation
in response to the pressure exerted. lows trials with various prosthetic compo-
>a- as there is so little available evidence
Regardless of the type of control nent and control options. The bilateral
of to make conclusive recommendations transhumeral amputee shown ultimately
arrangement used, it should impose
of for components. CriticaJ to the suc- decided t hat body-powered control bilat-
the minimum amount of mental
:sis cess of this approach is the availability erally best served his needs.
loading on the user. In other words,
;er, of all component options and the
the control of the prosthesis should
1es technical ability to mix and match
not be so complicated as to make it limit the sensate area that is covered or
rol components from different manufac-
the primary object of the user's atten- encumbered by the device. Opposition
illy turers. The foundation of the proto-
tion.1 Faced with the complexity of posts (Figure 20), handi-hooks (Fig-
.on type prosthesis is a well-fitted inter-
high-level bilateral fittings, sometimes ure 21), and even myoelectric prosthe-
~es face for evaluation. A prototype
one seemingly small change in the ses can be fitted at the partial hand
LJ1d prosthesis may be used for periods of
control strategy can cause a chain re- level. Opposition posts are particularly
en- time ranging from a few hours for
action of control source interaction useful whenever one or more movable
hes very straightforward fittiITTgs to several
and render the prosthesis impractical digits remain. These devices are sim-
md montl1s for difficult situations in
for daily tasks. 1 Although hybrid ple, lightweight, and generally cover
ua- which several prosthetic options must
(electric- and body-powered) compo- the least amow1t of area. A handi-
f'ler be evaluated. Through the use of a
nents and hybrid input devices may hook provides the ability to grasp and
t is prototype prosthesis, the amputee,
provide the most desirable results, release in patients who lack one or
ible the family, and other concerned par-
these systems can be technically de- more movable digits; when these de-
manding, requiring a high degree of ties can evaluate and validate the effi- vices are fitted loosely, users can
cacy of any particular prostl1etic "sneak" out of the socket, leaving it at-
creativity and specialized knowledge
on the part of the prosthetist. In my component/control configuration tached by the control system while
iS a
experience, the benefits realized by through first-hand experience before they manipulate objects using their
ltCh completion of the definitive prosthe-
the the users of hybridized systems far sensate residual hand. Wrist motion
sis8 (Figure 19).
and outweigh the technical difficulties in should be unrestricted by the prosthe-
)OS, producing these systems. The key to sis as much as possible. Myoelectric
tem optimal prosthesis design for the bi- Fitting Considerations hands offer strong grip forces but also
lateral upper limb amputee is careful cover all of the sensate skin of the
use
attention to details.
by Level hand, so this drawback must be con-
1put
Partial Hand sidered.
ms-
ex- In patients with one or both limbs am-
Prototype Prostheses putated at the partial hand level, the Transradial
tion
and Because of the large variety of com- main prosthetic considerations are to Body-powered hooks and myoelectric
ent, ponents and controls available to the provide effective prehension and to systems have been proved effective for

Fi91
bila
acti
Figure 22 This bilateral wrist disarticulation amputee is shown wearing both his body- this
powered and his myoelectric prostheses. A, Both systems allow full elbow range of mo- torr
Figure 20 An opposition post can pro-
tion and retain forearm rotation by design. B, Electric-powered hands provide greater ced
vide a simple and robust device to en-
grip force and a more natural appearance than the voluntary-opening split hooks. This grif
hance t he function of a partial hand am-
amputee finds both sets of prostheses valuable and can match the most appropriate de-
putation with one or more movable
sign w ith a particular activity.
digits remaini ng. This man with trans-
radial/partia l hand amputations f inds his
cur
partial hand side most useful for fine moun;
tor tasks primarily because of the wealth not require a harness, thereby increas- more difficult as physiologic joints are
of information provided by his sensate ing the scope of work of the terminal lost. As noted, positive-locking wrists as
thumb. device. Some users find both types of and locking humeral rotators should gra
prostheses useful and routinely switch be considered for this patient popula- ele
between them depending on the type tion. Because of the loss of gleno- rer
of activities pursued (Figure 22). As humeral rotation in the transhumeral fur
discussed for the partial hand ampu- prosthesis, it may be beneficial for the up
tee, sensation is of critical concern for surgeon to perform an angulation os- mt
the transradial amputee. Exposed skin teotomy to enhance the amputee's pr<
can be desirable, especially for pa- ability to actively position the pros- 1ca
tients with longer transradial amputa- thesis in space 19 (Figure 24) . pr,
tions or wrist disarticulations. For the Independent donning of both arr
blind b ilateral transradial amputee, transhwneral prostheses is a primary
sensation is required for function. In St
goal for this population. This goal is
these patients, surgical interventions
almost always achieved when body w
such as a Kr ukenberg procedure or a dii
position control is used but may be
toe transfer to the forearm such as the aU
quite difficult when myoelectric con-
Vilkki procedure (Figure 23) should pr,
Figure 21 For the partial hand amputee trol is used, because a very snug
w ith no movable digits remaining, the
be seriously considered to produce a on
limb with manipulative capabilities. 18 socket is required to ensure consistent n
handi-hook prosthesis can offer a func-
skin-to-electrode contact. In my ex- sh
tional grasp. This design permits free mo-
tion at the wrist, improving the utility of Transhumeral perience, nearly ail bilateral upper ha
the device. Body-powered systems seem to offer limb amputees ultimately prefer a de
the best long- term results for the bi- body-powered prosthesis incorporat- co
the bilateral transradial amputee. lateral transhumeral amputee. How- ing a four-function forearm setup on pr
Body-powered hooks are robust, ever, electronic terminal devices and the transhumeral side compared with ad
lightweight, and offer the best fine elbows provide greater forces and, in myoelectric or hybrid control options m
manipulation capabilities. Myoelec- some patients, can complement the that they have tried. Despite this ex- jo
tric hands offer good cosmesis and a function of a body-powered prosthe- perience, electronic control of one or ca
powerful grip force with acceptable sis worn on the dominant side. The more components may be advanta- C<:
manipulative function . Myoelectric ability to easily and securely position geous for some patients, particularly 01
systems for transradial amputees do the terminal device in space becomes when the requisite fo rce and/or ex- tb

theses. Once the residual limbs stabi-

lized in size, myoelectrically con-
trolled prostheses also were provided.
Compression was provided by elasti-
cized stockinettes whenever the pros-
theses were not worn to reduce swell-
ing and prevent rebound edema. The
initial terminal devices were both
voluntary-opening devices, with a
canted Hosmer SX hook (Hosmer
Dorrance) on the dominant right side
and a lyre-shaped Dorrance 555
(Hosmer Dorrance) on the left. Two
hook tension bands were provided on
each hook initially to reduce the
Figure 23 Sensation is critical for blind Figure 24 This t ransh umeral/shoulder dis-
bilateral transradial amputees, and thus amount of force required for opera-
articulation amputee benefits from an
active prostheses have little to offer. For angulation osteotomy on his right arm tion. More hook tension is provided,
>dy- this patient, a Krukenberg procedure per- that facilitates physiologic humeral rota- in half-band increments, as quickly as
mo- formed on the left side and a Vilkki pro- tion, w hich improves rotational stability the amputee can tolerate the added
ater cedure on the right provide a variety of and provides added positioning control pressure in the sockets and on the
This gripping options. of the prosthesis. harness straps. Six to eight tension
· de-
bands are expected to be used on each
cursion for body-powered control are in a similar manner as used for the terminal device to provide a reason-
unavailable. dominant prosthesis. In my practice, able amo1mt of pinch force. Wrist
, are Suspension/control options, such flex:ion units are mounted on con-
the dominant prosthesis of the bilat-
rists as silicone suction sockets with inte- eral pair is configured with mechani- stant friction wrists bilaterally. The
)U]d gral myoelectric contacts and novel cal, cable-actuated components simi- prostheses are suspended using flexi-
ula- electronic control input options cur- lar to the four-function setup, and the ble hinges, triceps pads, and a North-
!nO- rently under development, may offer nondorninant side incorporates either western University ring harness. The
ieral functional advantages for bilateral all electric or hybrid components to amputee quickly learned to use the
r the upper limb amputees. The develop- provide complimentary functions. 1 prostheses for daily self-care activities
l os- ment of methods to easily don. the The electronic prosthesis should use and was able to don and doff the
1tee's prostheses independently will be crit- dedicated variable-speed control of arms independently after the first
,ros- ical in order for such technology to be the prehensor, wrist, and elbow when- week of training. Under the care of a
practical for bilateral transhumeral ever possible. local occupational therapist, the pa-
amputees. tient returned home for continued
both
practice and for discovery of the
nary
Shoulder Disarticulation Case Studies functional challenges he would face.
,al is
When fitting the bilateral shoulder Upon the patient's return to the
body Case Study 1
disarticulation amputee, it is gener- rehabilitation facility 3 months later,
ty be
ally advisable to start with as simple a A 28-year-old man who lived with his he demonstrated basic competency in
con-
prosthetic system as possible. Often, wife and their 3-year-old child sus- feeding, oral/facial hygiene, dressing,
snug and toileting. He and his family
only the dominant side is fit initially. tained bilateral transradial amputa-
Lstent tions as a result of an electrical injury. were very eager for new prostheses
The complexity of control methods
y ex- His limbs were amputated at the mid- with myoelectric hands. He was par-
should be minimized, starting per-
lpper haps with only an activated terminal forearm level bilaterally, and he had ticularly interested in the better ap-
fer a device and elbow. As the patient be- no other injuries that would limit pearance of such hands but also
>orat- comes acquainted with the use of the prosthetic rehabilitation. Sixty days stated that the increased grip strength
lp on prosthesis, wrist function can be after the accident, his limbs were well would be of great value. Myoelectric
I with added, followed by addition of hu- healed. At this time, prosthetic op- prostheses were provided, including
>tions meral rotation and a locking shoulder tions were presented. Follow-up dis- Northwestern University self-sus-
is ex- joint. The nondominant prosthesis cussions focused on the advantages pending sockets, microprocessor-
,ne or can be fitted once the user has gained and disadvantages of myoelectric based two-site proportional myoelec-
,anta- confidence in the use of the prosthesis hands and cable-operated hooks. The tric control, electronic wrist rotators
ularly on the dominant side. Complexity on initial prosthetic prescription called with a quick-disconnect feature, and
)r ex- the nondominant side can be staged for body-powered preparatory pros- interchangeable electronic hands and

....
Otto Bock greifers (Otto Bock, Dud- thesis on the right side and only a control of elbow, prehension, and SUI
erstadt, Germany) . The amputee was frame-style cap on the left side, de- wrist rotation. Initially, a linear trans-
pleased with the appearance and signed to avoid the unhealed areas. Succ
ducer was used to prod uce variable-
found certain activities, such as pull- The cap serves as a secure anchor era!
speed control of the Boston electronic
point for the suspension and control achi(
ing up his socks, easier to perform elbow operated by shoulder elevation
of the right transhumeral prosthesis. ex:pe
with the greater pinch force. He also harnessed using a "lift-through"
fotmd manipulation of small objects A Hosmer SXA hook (Hosmer Dor- limb
socket design. Constant-speed control
rance) is used, along with a wrist flex- with
to be more difficult than with the ca- of a greifer is provided by a simple
ion unit and a constant friction wrist. fit g
ble-operated hooks. He realized that rocker switch activated by chin nudge
The lever for the flexion lock is ex- requ
although neither type of device is control. During the next 4 months,
tended by attaching an 18-mm metal indt
ideal, both have advantages. After incremental changes were made to the
washer so the amputee can actuate it com
3 years, the patient still used both prosthetic design to gradually meet
without assistance by pulling it vice:
body-powered and myoelectric pros- the original design objectives. At the
against his knee, hip, or other object. tors.
theses on a routine basis and could end of this time, variable-speed con-
An internal locking elbow with a lift men
perform all necessary self care with
trol of the prehensor and wrist rota- face,
both sets of prostheses. He used the assist is fitted with an adjustable el-
bow flexion attachment fixture to op- tor was achieved using FSRs paired in loss
body-powered prostheses exclusively
timize the amount of force and excur- a rocker configuration and activated Eacl
on his job as an inspector for the
sion required to operate the by nudge control. A third FSR was tee t
power company (where he was em-
used to cycle the lock for the LTI- ual ·
ployed at the time of his injury) be- prosthesis. The prosthetic sockets are
worn over a T-shirt that has been tai- Collier (Liberating Technologies, lnc) desi
cause of problems with occasional
lored to fit snugly over the residual shoulder joint in an alternating fash- tea11
inadvertent opening or closing of the
limbs, acting as a one-piece cotton ion (ie, one push locks, one push un- oph
electronic hands when near sources of
torso sock. A Spectra control cable in- locks) also activated by the chin. The serv
high-powered electronic interference,
side a Teflon-lined housing was used locking shoulder joint permits termi- thet
but he generally preferred the myo- quil
electric prostheses for use when not to reduce friction as much as possible. nal device activation above shoulder
The plan was to complete training level, a function not possible on the tior
in his work environment.
and practice \>\'1th this relatively sim- right transhumeral side because of
accc
ple component configuration and eno
the limited bony lever arm. When the
Case Study 2 then to add dynamic wrist rotation tio.r
terminal device is overhead, the chin
A 48-year-old man who lived on a and flexion using a four-function 1
nudge control prevents visual track-
300-acre farm with his wife and two forearm setup within approximately atte
ing of objects being grasped. To alle- a o
grown sons, where they grow floral 1 month. viate this problem, control of the ter- sim
greenery, lost both arms as a result of Upon the amputee's return to the minal device was changed to shoulder wei
an accident involving the power take- rehabilitation facility 1 month after elevation using the linear transducer, crit
off on his tractor. His dominant right his initial fitting, he was progressing and the elbow was controlled propor- Pro
arm was amputated at the midtrans- nicely using his single prototype
humeral level, and he had a left shoul- tionally using a pair of FSRs in a loo
prosthesis. He could feed himself chin-activated rocker fashion. Al-
der disarticulation. Thirty days after some foods after assisted setup, he cor.
though the patient used his right fee,
the injury, he was seen at a rehabilita- could dress himself partially, and he
tion facility for prosthetic fitting and body-powered transhumeral prosthe- tro
was nearly independent in toileting
training. The transhumeral limb was sis for most daily tasks, he found the anc
with a bidet, requiring assistance in
well healed, but his left side still had increased gripping and lifting capabil-
redressing. The new wrist setup was
some open wounds and was quite ities of the electronic prosthesis in- abl
installed, and the left shoulder disar-
sensitive to touch. valuable. One year after the final fit- gie
ticulation was fitted with an electri-
This patient had a very pragmatic ting, the patient could independently ne,
cally powered prosthesis using a tem-
1,
attitude toward prostheses. From the don and doff both prostheses; prepare em
I, porary socket as a foundation. By
first consultation, he expressed an in- certain simple meals, although his an
using a fully electrically powered
terest in wearing the most functional wife assisted with most of the setup; ity
II prosthesis on the left side, separation
prostheses so that he could continue of control can be readily achieved, toilet himself in his own home, using she
to be productive on the farm. He had a bidet and strategically mounted thf
and all biscapular abduction and gle-
'
known other amputees who were hooks to assist in pulling up his pants; art
nohumeral motions can be devoted to
farmers in his community and readily and complete daily oral/facial hygiene sol
the operation of the dominant side
accepted the utilitarian appearance of using an electric razor and tooth- vie
prosthesis.
a hook-type prehensor. Initially, he brush mounted on a flexible goose- tat
This control system was designed
thi
was fitted with a body-powered pros- to provide variable-speed dedicated neck.

Chapter 25: Bilateral Upp er Limb Prostheses 325
good use of these tools, as they strive unstructured environments: Extended

tnd summary physiological proprioception, position
ns- for functional independence and meet
Successful rehabilitation of the bilat- the challenges of daily life. control, and arm prostheses, in Pro-
>le-
eral upper limb amputee is best ceedings of the International Conference
,nic on Rehabilitation Robotics, 1990,
achieved with the collaboration of an
ion
experienced team. Bilateral upper References pp 25-40.
gh" funb amputees, particularly those 12. Childress DS: Upper-limb prosthetics:
l. Uellendahl JE, Heckathorne CW: Cre-
trol with amputation at a high level, bene- ative prosthetic solutions for the per- Control of limb prostheses, in Bowker
1ple fit greatly from prosthetic fitting and son with bilateral upper extremity JH, Michael JW (eds): Atlas of Limb
dge amputations, in Atkins D, Meier R Prosthetics: Surgical, Prosthetic, and
require other assistive technologies,
ths, (eds): Functional Restoration of Adults Rehabilitation Principles, ed 2. Rose-
including automobile modification, mont, IL, American Academy of Or-
the communication devices, self-care de- and Children With Upper Extremity
Amputation. New York, l\1Y, Demos thopaedic Surgeons, 2002, pp 175-198.
1eet vices, and nonprosthetic manipula- (Originally published by Mosby-Year
the Medical Publishing, 2004, pp 225-237.
tors.20 All of these modalities aug- Book, 1992.)
on- 2. Uellendahl JE, Heelan JR: Prosthetic
ment the function of the user who is 13. Simpson DC: The choice of control
lta- management of the upper limb defi-
faced with the tremendous functional system for the multi-movement pros-
cient child, Alexander M, Molnar G
l in loss of amputation of both arms. thesis: Extended physiological propri-
( eds): Physical Medicine and Rehabilita-
1ted Each new bilateral upper limb ampu- oception (E.P.P.), Ln Herberts P, Kade-
tion: State of the Art Reviews. Philadel-
was tee must be approached as an individ- fors R, Magnusson R, Petersen I (eds):
phia, PA, Hanley & Belfus, 2000, vol
.:fi- ual whose particular needs, goals, and The Control of Upper-Extremity Pros-
14, no 2, p 232.
desires should be the focus of the theses and Orthoses. Springfield, IL,
ne) 3. Malone JM, Fleming LL, Roberson J, et Charles C Thomas Publishers, 1974,
1sh- team. The fitting methods and philos- al: Immediate, early, and late postsur- pp 146-150.
un- ophies discussed here should only gicaJ management of upper-limb am-
14. Doubler JA, Childress DS: Design and
rhe serve as examples of successful pros- putation. J Rehabil Res Dev 1984;21:
evaluation of a prosthesis control sys-
mi- thetic rehabilitation. Variations are re- 33-41.
tem based on the concept of extended
.der quired based on the unique presenta- 4. Billock JN: The Northwestern Univer- physiological proprioception. J Rehabil
the
tion of the individual, taking into sity supracondylar suspension tech- Res Dev 1984;21:19-31.
account his or her expressed prefer- nique for below-elbow amputations.
of 15. Heckathorne C, Childress D, Grahn E,
ences for particular prosthetic op- Orthot Prosthet 1972;26:16-23. Strysik J, Uellendahl J: E.P.P. control of
the
tions. 5. Sauter WF, Naumann S, Milner M: A an electric hand by exteriorized fore-
hin three-quarter type below-elbow socket
Experience has shown that car eful arm tendons, in Proceedings of the
1ck- for myoelectric prostheses. Prosthet
attention to socket fitting, provision of Eighth World Congress of the Interna-
1lle- Orthot Int 1986;10:79-82. tional Society for Prosthetics and
a control system that is reliable and
ter- 6. McLaurin CA, Sauter WF, Dolan CM, Orthotics. 1995, p 101.
simple to use, and m inimizing the
lder weight of the prosthetic device are Hartmann GR: Fabrication procedures 16. Heckathorne CW, Uellendahl J, Chil-
.cer, critical for successful rehabili tat ion. for the open shoulder above-elbow dress DS: Application of a force-
>Or- socket. Artif Limbs 1969; 13:46-54. actuated position servo controller for
Prostheses that are s uccessful in the
n a long term offer the bilateral amputee 7. Bush G: Powered Upper Extremity Pros- electric elbows, in Proceedings of the
Al- thetics Programme: Above Elbow Fit- Seventh World Congress of the Tnterna-
comfort, aesthetics, proprioceptive
ight tings. Hugh MacMillan Rehabilitation tional Society for Prosthetics and
feedback, donning independence, con-
Centre, Rehabilitation Engineering Orthotics. 1992, p 315.
the- trol reliability, variable-speed control,
1 Department Annual Report, 1990, pp 17. Carlson LE, Veatch BD, Frey DD: Effi-
the and positive locking joints. 35-37. ciency of prosthetic cable and hous-
.bil- Clinical fittings are based on avail-
8. Uellendahl JE: Upper extremity myo- ing. J Prosthet Orthot 1995;7:96-99.
in- able components and control strate- electric prosthetics. Phys Med Rehabil 18. Vilkki SK: Free toe transfer to the fore-
fit- gies suitable for their operation. As Clin N Am 2000;11:639-652. arm stump following wrist amputa-
ntly new components and control schemes tion: A current alternative to the
9. UeUendahJ J, Heckathorne C: Pros-
,are emerge, they should be evaluated with thetic component control schemes for Krukenberg operation. Handchir
his an open mind, and their potential util- bilateral above-elbow prostheses, in Mikrochir Plast Chir 1985;17:92-97.
tup; ity for bilateral upper limb amputees Proceedings of the Myoelectric Control 19. Marquardt E, Neff G: The angulation
sing should be considered carefully. Fitting Symposium. University of New Brun- osteotomy of above-elbow stumps.
1ted the bilateral upper limb amputee is an swick, 1993, pp 3-5. Clin Orthop 1974;104:232-238.
.nts; art as much as a science, and potential 10. lvko JJ Sr: independence through hu- 20. Weir RF: Robotics and manipulators,
iene solutions should not be limited to pre- meral rotation in the conventional in Olson DA, DeRuyter F (eds): Clini-
)th- vious options. Despite the many foni- transhumeral prosthetic design. cian's Guide to Assistive Technology. St.
tations of state-of-the-art arm pros- J Prosthet Orthot l 999;11:20-22. Louis, MO, Mosby, 2002, pp 281-293.
ose-
theses, bilateral amputees often make 11. Heckathorne CW: Manipulation in

Prosthetic Adaptations in
Competitive Sports and Recreation
Robert Radocy, MS
Introduction
A continuing challenge in prosthetics Social and cultural assessments re- particular activity is the primary chal-
is providing technology that allows lated to family and peer support are lenge. Adequate prehension is some-
the amputee to compete and excel in important, and understanding the pa- times a consideration but not always.
sports and recreation while using an tient's motivation, cooperation, and Gross motor movement is most likely
upper limb prosthetic device. Creative communication capabilities enhances required. Because pain limits perfor-
solutions cmrently exist, and new de- the therapeutic process. mance, secure and comfortable sus-
signs are continually evolving. 1-3 See The patient must understand that pension is paramount.
the lists of resources and product successful prosthetic and physical re-
habilitation is a prerequisite for opti- Insurance and Funding
manufacturers provided at the end of
this chapter for further information. mal performance. A state-of-the-art Few private insurance policies cover
In the 1990s, research and develop- prosthesis .,-.,ill not provide optimal avocational prostheses, even though
performance to a user who is not such care is routinely provided by the
ment on activ:ity-specific prostheses
physically capable of taking advantage Shriners and Scottish Rite hospitals
intensified at the urging of amputees
of its features. Conversely, optimal and the United States Department of
who were interested in participating
performance will not be achieved Veterans Affairs. Consumer demand
competitively in sports and recre-
with a prosthesis that does not pro- and the influence of proactive na-
ational activities. Many prosthesis us-
vide a level of technical sophistication tional organizations such as the Am-
ers experience great satisfaction and
that matches or challenges the user's putee Coalition of America (ACA)
self-assurance when they can success-
physical capabilities. may lead to progress in obtaining in-
fully return to a favorite sport or rec- surance coverage. Workers' compen-
reation. This chapter focuses on muJ- Function sation insurance related to lin1b loss is
tiple approaches to achieving more progressive and usually includes
Function, performance, and limb
performance using specialized pros- prostheses for sports and recreation.
morphology are interrelated. Biman-
thetic accessories, custom prostheses,
uaJ performance becomes increas-
and modified sports and recreational Safety
ingly difficult to achieve with higher
equipment. levels of limb loss or bilateral involve- Safety must be viewed from two per-
ment. High-level transhumeraJ ab- spectives. First, a prosthesis must al-
General sence forces unilateral dominance and low the user to perform activities
performance, and function and per- safely. Second, it must be safe to use
Considerations formance options decrease with around others, protecting them from
Patient Assessment higher levels of limb absence. Because injury as well. In competitive physical
A thorough assessment of the pa- unilateral tramradial absence is the contact sports, padding the definitive
tient's physical capabilities (muscle most common upper limb absence, prosthesis with 5-mm-thick neoprene
hypertrophy, strength, range of mo- most prosthetic solutions are de- with nylon laminated to both sides
tion, etc), as well as personal sports signed for this level. (divers' wet suit material) provides an
and recreational goals is critical and Sports and recreational act1V1t1es excellent cushion. The neoprene can
provides a baseline from which to de- are highly function -specific. Duplicat- be sized to be slightly smaller than the
velop a prosthetic rehabilitation plan. ing the biornechanics required in a diameter of the prosthesis and de-

vides a prosthesis that the user can figure-of-9 harness, provides excellent Ali
tolerate under the severe loads that terminal device operation without the
are generated during sports and rec- cumbersomeness and discomfort
AliE
whi
reational activities. Roll-on liners sometimes associated with a tradi-
made of silicone or equivalent materi- pro
tional figure-of-8 harness system.
als provide an excellent interface be- tor
Specialized axilla padd ing options im- not
tween the limb and the prosthesis and prove comfort. Polypropylene strap
can significantly enhance perfor- fab:
materials and traditional Dacron Pro
mance. Prostheses to be used in water webbing provide options in harness
sports usually require some type of ma:
Figure 1 Self-suspending prosthesis de- design, construction, strength, color, rea·
sign wit h broad brim and cross-bar strap. roll-on liner or external suspension
and comfort. ran
(Courtesy of TRS Inc, Boulder, CO.) sleeve because of the inherent lubric-
ity of water. The high levels of surface gro
Power Options
friction or traction created by roll-on sivt
liners serve to increase suspension. Most custom sports prostheses are per
signed to slip over the device, provid- Liners differ in design and elastic- designed around conventional body- tral
ing a snug, nonslip cover. Neoprene ity. Some types of shorter limbs bene- powered technology, which has to ;
sleeves also add buoyancy in the wa- fit more from custom-made liners; proved to be durable and reliable. ter1
ter; a 5-mm-thick cover will float a other limbs generate adequate sus- Shock, vibration, and exposure to mo
conventional transradial prosthesis. pension with standardized molded high-moisture or water environments Sli1
For high school sports or intercol- liners. Liner thickness and stretch typically have required the use of cat
legiate athletic programs, specific characteristics are factors that affect body-powered systems. However, ex- shi
waivers may be required to allow the suspension and performance. Some ternally powered prostheses have been or
athlete to compete while wearing a liners have both longitudinal and cir- used in sports and recreational activi-
prosthesis. Local or regional athletic cumferential elasticity, whereas others ties, and their lack of cable and har- act
authorities can provide written waiv- have limited or no longitudinal ness suspension may improve the cia
ers for high school sports such as bas- stretch. Users with short residual user's performance. As advances oc- ca1
ketball, where the use of a con- limbs will prefer liners with little or cur in the technology of ex'ternally ho
ventional prosthesis is generally no longitudinal stretch. Longitudinal powered prostheses, including im- tht
prohibited. Rule books for high stretch can result in limb migration proved resistance to water and the wr
school sports can be obtained from and loss of suspension, especially in ability of the components to with- rat
the National Federation of State High activities where dfrect distal pulling is stand shock and vibration, the use of ua
School Associations (see list of re- involved or where forearm or elbow the
externally powered limbs in these sit-
sources). Recreational, intramural, flexion and extension under resis- the
uations will no doubt expand.
and community programs usually do tance is required (exercises such as ali
not have such rigid regulations. triceps press-downs or latissimus Materials bo
pull-downs). Thicker liners can pro- li11
A custom sports prosthesis should fit
vide some additional comfort around e1-J
Prosthesis Design bony prominences but do add to the
well, be comfortable, support weight, ra,
and handle a variety of loads. A wide
Considerations overall bulk of the prosthesis. If a thin
variety of high-strength materials and
ill
Socket Designs and liner is used, a partial liner of padding (1

is suggested, as described earlier. resins lend themselves to high- th
Options performance prostheses. Use of Kev- be
A supracondylar or self-suspending Harnesses lar and carbon-reinforced fabrics, ca
prosthesis is very useful in providing Many sports prostheses do not re- ultra-high molecular weight polyeth- or
adequate suspension without inhibit- quire a harness. Harnesses can limit ylenes, and compatible resins results th
ing range of motion. A wide brim or restrict the range of motion rein strong, lightweight prostheses that ar
around the socket transfers distal quired for a particular activity, such provide safe, reliable bimanual per- a:r
prosthetic loads to the humerus and as the motion needed to carry formance. Stainless steel or titanium Si
creates additional leverage-enhancing through a golf swi ng. In activities that reinforcement is sometimes used in liif
cable excursion during elbow flexion, require active controlled prehension, the construction of prostheses, pre- re
when a cross-bar assembly is properly a cable and harness can be used. Con- hensors, and sports accessories. Other pl
applied (Figure 1). trolled prehension also can be materials include structural nylons, er
A self-suspending socket designed achieved by an externalJy powered aircraft-grade aluminum, and a vari- cc
with a partial liner (padding) over the prosthesis. A modified, adjustable ex- ety of modern, resilient elastomers A
elbow condyles and olecranon pro- cursion, such as a Northwestern such as polyurethane. t:a

Chapter 26: Prosthetic Adaptations in Competitive Sports and Recreation 329
:nt Alignment tored into the prosthetic design. Ex- and extension), and (5) humeral flex-
he perimentation with loads and forces ion, extension, abduction, and adduc-
Alignment is an important factor
>rt before the final lamination process tion.
when designing and constructing a
:ii- can help avoid the need and expense These motions rarely occur in iso-
prosthesis. Alignment is always a fac-
m. of refabrication. lation but in progressive and coordi-
tor in a lower limb system but may
n- nated harmony to create a limb ac-
not be as closely monitored in the
ap Cosmesis tion. An example is the "wrist break"
fabrication of upper limb prostheses.
on In most sports and recreational activ- that occurs in normal limbs when a
Proper alignment is crucial to perfor-
ess ities, function rather than cosmesis is baseball bat or similar object is swung
mance. Because many sports and rec-
or, the goal. However, in activities such as through completely. A baseball bat
reational activities demand a wide
dance, aerobics, and floor exercise, swing that culminates in a wrist break
range of upper limb motion, such as
where cosmesis may be a concern, ef- and follow-through is a complicated
gross motor arm activity, an exces-
forts should be made to create a pros- interaction of not only humeral, fore-
sively preflexed prosthesis can limit
thesis that is lifelike in contour, tex- arm, and wrist biomechanics, but also
ne performance. A prosthesis with a neu-
biomechanics that involve the torso,
ly- tral or preextended alignment (socket ture, and color. Muscle definition can
hips, and lower limbs.
ias to arm centerline) may be a better al- be sculpted into the prosthetic foam
Traditional prosthetic limb tech-
1le. ternative. Additionally, the wrist before lamination to enhance cosme-
nology provides for only certain de-
to mounting angle must be considered. sis. A flat exterior finish rather than a
grees of freedom and therefore, only
nts Slight changes in wrist angle can glossy finish might be preferred. Soft
certain motions. Specialized pros-
of cause the load on the residual limb to cosmetic covers might be an option
thetic components and accessories
~x- shift, sometimes causing discomfort but are not always practical because
can fill this gap.
:en or creating instability. of their limited durability.
vi- Archery and weight lifting are two
ar- activities in which alignment is espe- Biomechanical Activities
the cially important. In archery, a signifi- Considerations
Sports and recreational activities can
'.>C- cant distal load occurs on the arm To achieve maximum performance be grouped according to their biome-
t!ly holding the bow. If the alignments of with a prosthesis in a particular sport chanical demands, and parallel solu-
m- the socket to arm centerline and the or recreational activity, the biome- tions can apply to activities that have
the wrist to arm centerline are not accu- chanical aspects and demands of the similar biomechanical requirements.
th- rate, balancing this load on the resid- activity need to be understood and Certain activities are unique, how-
ual limb becomes very difficult and duplicated as much as possible. Du-
of ever, and specific accessories or solu-
the load feels unstable. The shorter
;it- plicating the biomechanics provides tions have been devised to enhance
the residual limb, the greater the role
for the control and transfer of energy performance in these areas.
alignment plays in the design. The
and motion from the body and torso
bow must load the prosthesis, residual Ball Sports, Aerobics,
through the anatomic and prosthetic
limb, upper arm, and shoulder prop-
fit limbs, resulting in or facilitating some Dance, Tumbling, Skating
erly for stability and shooting accu-
:ht, predetermined action. This large and varied group of activi-
racy. Improper alignment can result
ide In some instances, the prosthetic ties, including soccer, volleyball, bas-
in three undesirable situations:
md limb can be used to generate energy ketball, and similar sports, shares
(1) the user may not be able to draw
?;h- (ie, prehension via a cable or external some biomechanics. These activities
the bow; (2) the user may draw the
ev- power source). However, its primary usually involve the need for bimanual
bow but once it is drawn, may be in-
ics, capable of supporting it comfortably; use is to transfer energy or, in some control (two-handed opposition and
th- or (3) the user may draw and support instances, store energy and then manipulation), energy storage, stabil-
.tlts the bow but not be able to shoot the transfer it. Prosthetic components or ity, balance, and safety. Traditional
hat arrow accurately because of the forces accessories that provide or allow for prehension (opposed thumb and
,er- and torque induced into the system. various degrees of freedom enable the forefinger grasp) are not necessarily
um Similar problems can arise in weight efficient transfer of energy and power. important. Historically, cosmetic
111 lifting. For example, bench pressing Biomechanics in the upper limb pri- hands were used to try to meet these
,re- requires a strong stable prosthetic marily provide for the following mo- needs; however, they were not de-
her platform. Improper alignment may tions: (1) basic prehension (opposed signed to provide the strength, dura-
IDS, create intolerable or unstable load thumb grasp and cylindrical grasp), bility, and function that more modern
ni- conditions that compromise safety. (2) wrist flexion and extension, (3) accessories can provide.
ters Alignment that facilitates the specific forearm pronation and supination, Anthropomorphic terminal de-
tasks desired must be carefully fac- (4) elbow flexion (forearm flex:ion vices that enhance bimanual control

Figure 2 Super Sport Hands. (Courtesy of Figure 3 Free Flex Hands. (Courtesy of Figure 4 Rebound Bask.e tball Hand.
TRS Inc, Boulder, CO.) TRS Inc, Boulder, CO.) (Courtesy of TRS Inc, Boulder, CO.) Fig
TR:
tht
sig
cit
Ere
pli
ty1
an
fie
us
is
Figure 5 Rebound Basketball Hand. Figure 6 Amputee Golf Grip. (Courtesy Figure 7 Golf Pro, right hand model.
(Courtesy of TRS Inc, Boulder, CO.) of TRS Inc, Boulder, CO.) (F
(Courtesy of TRS Inc, Boulder, CO.)
to
chanics used in controlling a basket- and found to be reliable, but they th
ball. have certain limits to their range of au
Externally powered hands might motion. Another alternative that has ce
have some application in some of proved effective is the flexible cou- en
these activities, but their configura- pling. A flexible coupling was possibly an
tion does not allow for accurate bi- first used by prosthetist J. Caywood S\1
manual ball control. They also do not (Robin-Aids) in developing a golf de- ba
provide the energy storage needed for vice.
duplicating dynamic wrist and hand A high-strength flexible couple can WI
action. provide a smooth, efficient, and con- ce
trolled transfer of energy. The Ampu- th
Baseball, Softball, Golf, tee Golf Grip, Golf Pro devices, and
Figure 8 Grand Slam baseball bat acces- Bowling Grand Slam baseball and softball bat m
sory. (Courtesy of TRS Inc, Boulder, CO.) These activities involve a complex accessories (TRS Inc) (Figures 6 b,
combination of biomechanical ele- through 8) use the flexible coupling je,
ments. Prehension is important but design. The Amputee Golf Grip and in
and function are available and have
secondary to the development and the Grand Slarn devices require the ar
been designed to be flexible, safe, and b,
smooth transfer of kinetic energy into grasp of the opposite hand to help en-
store energy (Figures 2 and 3). When
the projectile involved. Duplicating gage the devices. The Golf Pro differs UJ
externaJ force is applied to these de- h,
the degrees of freedom that occur in in that it slides up the shaft of the golf
vices, they produce an action similar the forearm and wrist allows for the b(
club and "jam fits" onto the grip.
to wrist and hand flexion and exten- transfer of energy into the ball. Ava- A variety of other individual, cus- T
sion. The Rebound Basketball Hand riety of studies have been conducted tom solutions have evolved to suit u:
(IRS Inc, Boulder, CO) (Figmes 4 on how to duplicate the biomechanics specific needs and preferences in golf.
and 5) takes the concept to a higher involved. Simple mechanical joints In some designs, the golf clubs are D
level of complexity by attempting to such as ball-and-socket joints and equipped with "snap on" connectors U:
duplicate certain hand and finger me- universal-type joints have been tested to fit directly into the end of the pros- w

Figure 11 Grip prehensor for the steer-

ing w heel. (Courtesy of TRS Inc, Boulder,
and. CO.)
Figure 9 Power Swing Ring. (Courtesy of
TRS Inc, Boulder, CO.)
thesis with no flexible joint. Other de-

signs attempt to "lock in" the angle of
club swing and limit the degrees of Figure 10 Bowling Ball Adaptor. (Cour-
freedom involved. This is accom- tesy of Hosmer Dorrance Corp, Campbell,
CA.)
plished by using a single-axis hinge-
type joint mounted at the appropriate
angle. control. The device uses an expa nd-
Wooden bats can be easily modi- able plug controlled by cable excur-
fied. The Power SwiJ1g Ring (TRS Inc) sion to release the bowling ball. The
uses a simple swivel mechanism that ball reqtrires minor customization to
is attached to the bottom of the bat receive the plug adapter.
1odel.
(Figure 9). Figure 12 Grip prehMsor for a stick shift.
In all cases, hand dominance needs Steering, Driving, Riding (Courtesy of TRS Inc. Boulder, CO.)
to be considered, as well as the side of Activities that involve vehicle riding
they the hand absence. Significant vari- and control have similar biomechru1i-
ge of ances in the design of prosthetic ac-
cal demands. These activities require
t has cessories are dictated by these differ-
spontaneous grasp ru1d release capa-
cou- ences. A device designed to allow an
bility. Bimanual control and adequate
ssibly amputee with a left hand absence to
prehension usually a1·e needed to ma-
wood swing " right handed" in either golf or
nipulate throttles, clutches, and brake
lf de- baseball usually will not work for an
and shift levers simultaneously or in a
amputee with a right hand absence
synchronous manner. Appropriate
le can with a similar swing. An array of ac-
hru1d grasp configuration (opposed
l con- cessories has evolved to accommodate
thumb and forefinger) is needed to
.mpu- these differences. Figure 13 Grip prehensor for a motorcy-
conform to the rounded or cylindrical
;, and Bowling biomechanics parallel cle. (Courtesy of TRS Inc, Boulder, CO.)
many of the motions of golf and controls.
111 bat
baseball. Instead of swinging an ob- Spontaneous release is important
res 6
to free the rider from the vehicle con- Externally powered terminal de-
L1pling ject to hit a projectile, however, bowl-
ing requires a pendulum action of the trols in the event of a spill or crash. vices and hands function well in con-
p and
Modern voluntary-closing prehensors trolling most vehicles, with the excep-
re the arm and a hand release to delive1· the
ball. Because bowling is essentially a (Figures 11 through 13) work well in tion of watercraft, which is usualJy
:lp en-
unilateral activity, a person missing a these applications. Most vehicle con- prohibited because of the likelihood
differs
hand has the option of relearning to trols require arm and elbow extension of prosthesis immersion in water. The
:ie golf
bowl with the nondominant hand. and fl.exion . These biomechanical prehension of approximately 25 kg
p.
This may be preferred over trying to motions control voluntary-closing- (of force) produced by myoelectric
1, cus-
:o suit use a prosthetic accessory. type devices. Gross motor activity in and similar devices is adequate for
.n golf. The Bowling Ball Adapter (Hosmer general helps to maintain prehension controlling vehicles in most situa-
1bs are Dorrance Corp, Campbell, CA) (Fig- without the need for additional cable tions. Quick release of the controls is
1ectors ure 10) can be used by those who excursion control. Release is auto- possible, although not as instanta-
e pros- wish to use their prosthesis for ball matic when cable tension is relaxed. neous as release by the human hand.

sion, and q uick grasp and release ca-

pability. They differ from the last se-
ries of activities in that they usually
require a separate piece of equipment
that is controlled bin,anually. Gross
motor upper limb activity is typical.
Pulling and pushing, including the
mechanics of humeral flexion, exten-
sion, abduction, and adduction and
elbow flexion and extension, are in-
volved. Body-powered voluntary clos-
ing prehensors such as the Grip 3
Figure 14 Grip 3 prehensor for kayaking.
--~ (TRS Inc) (Figures 14 and 15) have
proved to function well, providing the Fig
necessary prehension and rapid grip (CG
and release capability. Voluntary- zor
opening devices are not recom-
mended because of their lower grip tht
force . Wet suits can inhibit the action wi
Figure 15 Grip 3 prehensor for windsurf- of a cable and harness system; how- po
ing. (Courtesy of TRS Inc, Boulder, CO.) ever, wearing the harness outside the is :
wet suit can usually eliminate the in!
problem. Externally powered arm wr
electronics may be compromised in
water sports activities. an
Mountaineering requires gripping pr,
strength and reaching, grasping, and na
rope handling capabilities. Voluntary- ele
closing prehensors (Figure 16) have pr
performed satisfactorily for many he
mountaineering and climbing tasks, fyi
but a plethora of specialized equip- fa,
Figure 16 Grip prehensor for mountain- Figure 17 Custom mountaineering acces-
eering. (Courtesy of TRS Inc, Boulder, CO.) sory. (Courtesy of TRS Inc, Bo ulder, CO.)
ment exists in thjs sport. Specia]ized th
training is required to ensure safety. te1
Individual custom aids (Figure 17) re,
Split hooks and other voluntary- necessary. Selecting a prosthetic ac- have been developed by some enthu- Fis
opening types of cable-activated cessory that provides all the necessary siasts to more successfully participate Rt
prosthetic devices usuaUy are not ade- requirements is important to ensme in this type of activity. h,
quate because of the gripping config- safe, reliable control. Locking a prosthetic device onto a er
uration and inability to maintain Special "dual-action" bicycle brake kayak or canoe paddle, windsurfer pr
grasp under cable load. Typically they levers (TRS Inc) allow both front and boom, or ski rope handle can have fa- lU
"pry off" controls. Some swivel ring rear brakes to be actuated with one tal consequences. Loss of control in hi
adapters exist to enable split hooks to hand. Hydraulic systems on motorcy- rough conditions can cause the par-
better control automobile steering cles and other vehicles can be modi- ticipant to be thrown into and under w
wheels. fied to operate both the front and rear the water with no easy way to release ei
Locking onto vehicle handlebars, brakes simultaneously or synchro- the prosthetic grasp. In water skijng, sl:
steering wheels, and other controls is nously. Specialty custom shops and the speeds can be great enough to bi
unsafe and should be avoided. Moun- vehicle dealerships usually can help cause severe injury because of the im- fc
tain bicycles, off-road motorcycles, modify vehicles for safe control. pact or dragging that ensues if release u:
snowmobiles, aU-terrain vehjcles, and is not accomplished. ri
personal watercraft require control Water Sports,
Fishing, except fly fishing and smf fi.
and extra strength under most riding Mountaineering, Hockey casting, does not typically involve dy- Iv
situations. Maintaining grasp and These activities, including canoeing, namic upper limb motion. A prosthe- a1
control while pulling or pushing on kayaking, windsurfing, water skiing, sis serves to either power the reel or Ir
the handlebars or steering wheel is and fishing, require strength, prehen- control the rod. Direct attachment of fr

ca-
se-
ally
ent
:oss
cal.
the
:en-
and
in-
los-
p 3
iave
the Figure 18 Prosthetic fishi ng accessory. Figure 19 Chest harness f ishing platform.
grip (Courtesy of Texas Assistive Devices, Bra- (Courtesy of The Free Handerson Co, Va-
zoria, TX.) lier, MT.)
ary-
om-
grip the pole into the prosthesis is possible
Figure 20 Slap Shot hockey accessories.
tion with an accessory made for that pur- (Courtesy of TRS Inc, Boulder, CO.)
.ow- pose (Figure 18). Another alternative
the is a flexible rubber snow ski and fish-
the ing accessory from Hosmer Dorrance,
arm which provides a passive grip.
:I in Handling the reel with a prosthesis
and the rod in the anatomic hand is
ping preferred by some fishers . An exter-
and nally powered terminal device, myo-
:ary- electric hand, or a voluntary closing
have prehensor will provide enough pre-
11any hension for control of the reel. Modi-
asks, fying or padding the reel handle can
luip- facilitate grasping it with a prosthesis,
lized thereby improving control. Other al- Figure 22 Grip prehensor for a bow and
tfety. arrow. (Courtesy of TRS Inc, Boulder, CO.)
ternatives include custom prosthetic
17) reel adapters, electrically powered
LthU- fishing reels (available from Access to tivities. Devices for shooting a bow
ipate Recreation; see Resources), and chest Figure 21 Custom Canadian hockey ac- are designed to accommodate either
harness- supported fishing rod hold- cessory. (Courtesy of War Amps of Can-
holding the bow or drawing the bow-
1to a ada, Scarborough, Ontario, Canada.)
ers and apparatus that provide im- string. Some designs involve mecha-
urfer proved function for the high-level nisms for connecting the bow directly
re fa- unilateral amputee or persons with hockey stick attachment that accom- to the end of the prosthesis. Other de-
ol in hemiplegia (Figure 19).
modates either style of stick handling signs use a modified voluntary closing
par- A hockey stick can be controlled
(Figure 20). prehensor (Figmes 22 and 23) to hold
mder with a prosthesis by holding the stick
:lease Numerous custom adaptations the bow. The modifications tempo-
either at the top end or down on the
ciing, have been developed for individual rarily lock the prehensor onto the
shaft. In both cases, wrist and forearm
;h to amputees, especially for young ath- bow handle. Externally powered
biomechanics need to be duplicated
e im- letes. Prosthetists in Canada, in par- hands can create the required grip-
for efficient control and performance
!lease in puck handling. A simple swivel and ticular, have focused on prosthetic ping configuration and prehensive
ring or ball-and-socket joint may suf- adapters for hockey to meet their pa- strength to handle a bow. Slightly
I surf fice as a top-end control mechanism. tients' needs (Figme 21). modifying the bow's handle will im-
·e dy- More sophisticated hockey accessories prove control whether a prehensor or
1sthe- are commercially available from TRS
Archery, W eight Lifting a myoelectric hand is used. A simple
:el or Inc that provide both the degrees of A vaTiety of prosthetic approaches cushioned gripping surface formed
mt of freedo m needed and the type of have been taken to facilitate these ac- around the bow's handle allows for

Figure 24 Archery accessory. (Courtesy of

Texas Assistive Devices, Brazoria, TX. )
Figure 23 Grip prehensors for archery. (Courtesy o f TRS Inc, Boulder, CO.)
Fig l
TRS
Figure 25 Custom archery equipment.

Figure 26 Custom archery equipment . Figure 27 Grip prehensor w ith locking

(Courtesy of Wright Bow Brace, ltd.) pin accessory. (Courtesy of TRS Inc, Boul-
der, CO.)
prosthesis is needed to handle these

loads and accommodate the biome-
chan ics involved. Voluntary-closing Fig1
(Co,
prehensors modified with a locking
pin (Figures 27 and 28) have proved
to satisfy most of these demands. Split anc
hooks and other voluntary-opening- pre
type devices usually are not appropri- in I
ate. Externally powered devices also gro
Figure 29 N-Abler weight lifti ng acces- can provide access but are more lim- SUS
sory. (Courtesy of Texas Assistive Devices, ited in application because of their dee
Brazoria, TX.)
prehension range, durability, and anc
electronic controls. cor
Archers m1ssmg a hand can now Custom weight lifting devices have
d raw the bowstring using modified been developed as well. A simple Sv
commercially available release aids barbell- and dumbbell-holding acces- FiE
Figure 28 Grip prehensors for weight used by archers. The release aid con- sory has been designed to fit into the Gn
training. (Courtesy of TRS Inc, Boulder,
CO.)
nects via an adapter directly into the N-Abler prosthetic adapter from 3111(
end of the prosthesis, hooks onto the Texas Assistive Devices (Figure 29). bu1
bowstring, and can be activated by TRS designed the Black Iron Master pre
ease of centering and balancing the triggering a lever (Figure 24). Custom (Figure 30), a custom alternative ac- me
bow in the prosthesis. Centering the designs have evolved as well to suit cessory for extreme conditions and a I
hand or prehensor provides for a the individual archer's needs and professional-level performance and Occ
smooth draw and release of the arrow. preferences (Figures 25 and 26). competition. in~
No torque is induced into the bow be- Weight lifting typically involves Designs that can be used with a va- an<
cause of "too tight" grasp or imbal- heavy loads and a wide range of mo- riety of equipment types, such as bar- cat
ance in holding. tion; therefore, a high-performance bells and dumbbells and Universal na1

Chapter 26: Pr osthetic Adaptations in Competitive Sports and Recreation 335
yof
l
Figure 32 Hi Fly Fielder. (Courtesy of TRS
Inc, Boulder, CO.)
Figure 30 Black Iron Master. (Courtesy of

TRS Inc, Boulder, CO.) Figure 31 Baseball Glove Attachment.
Campbell, CA.)
king
3oul- Figure 35 Swim Fin. (Courtesy of TRS Inc,
Boulder, CO.)
hese rotated and reoriented to field in all

1me- body zones. In many fielding situa-
Figure 33 Freestyle Swimming accessory. Figure 34 Freestyle Swimming accessory. tions, this is not practical or possible.
1sing
(Courtesy of TRS Inc, Boulder, CO.) (Courtesy of TRS Inc, Boulder, CO.)
king An alternative is the Hi Fly Fielder
oved system (Figure 32) by TRS. This sys-
Split and Nautilus equipment, provide the zones above and below the waist tem replaces the glove entirely with a
ing- prosthetic user with greater flexibility while fielding balls. Powered or con- ball catching accessory that is styled
)pn- in training a broader range of muscle trolled pronation and supination after a lacrosse stick head. A large cus-
also groups. Designs such as a self- (wrist rotation) are not readily avail- tom mesh pocket provides for bi-
lim- suspending socket with a partial pad- able with a prosthesis. Externally directional catching. The user can
their ded liner, carbon fiber reinforcement, powered systems do provide some catch forehanded or backhanded, and
and and a roll-on liner provide for added terminal device rotation, but the ac- pronation and supination are not re-
comfort, performance, and safety. tion is slower than would be required quired for fielding.
have for competently fielding a ball in Similarly, pronation and supi na-
mple Swimming, most situations. tion i11 swimming can be avoided. In
cces- Fielding/Catching The Baseball Glove Attachment by a flexible paddle system, such as the
o the Grouping swimming with fielding Hosmer Dorrance (Figure 31) pro- Freestyle Swimming accessory from
from and catching may at first seem odd, vides one alternative. The cable- TRS (Figures 33 and 34), tbe paddle
29). but the biomechanics of controlled operated, voluntary-opening device flares open to create the resistance re-
[aster pronation and supination are com- with extended hook fingers is de- quired in the power stroke, and dur-
e ac- mon to these activities. In swimming, signed to fit into a first baseman's ing stroke recovery the flaps fold
and a natural pronation and supination glove. The player with a longer fore- back, allowing water to push past the
and occurs in "feathering" the hand dur- arm can pronate naturally and use paddle. This concept was first envi-
ing power and retrieval arm strokes this device. The midlevel to short sioned by Canadian prosthetist Rob-
a va- and motions. ln baseball and softball transhum.eral user cannot pronate ert Gabourie as overlapping fins be-
' bar- catching, the forearm must be pro- and supinate naturally. The terminal tween fixed fingers. TRS simplified
V'ersal nated or supinated to cover body device and glove must be manually the design into the "butterfly wing"

Figure 36 Ski Hand/Fishing Hand. (Cour- Figure 37 Ski 2. (Courtesy of TRS Inc,
FigUI
tesy of Hosmer Dorrance Corp, Campbell, Boulder, CO.) (Cou
CA.)
the gun must be held or stabilized by

paddle concept for ease in manufac- the prosthesis in some manner. A pis-
....
turing and to allow for easy modifica- tol grip or swivel ring can be added to spec
tion to match different hand displace- the forearm and grasped by a hook, but
ments. prehensor, or hand. A military strap is Figure 38 Amp-U-Pod camera accessory. can
(Courtesy of TRS Inc, Boulder; CO.) whi·
A swimmer with a long residual useful for adding stability for aiming
limb can use a simple rigid paddle at- hone
and firing. Triggering is possible, but
tached to the forearm to create the re- tl1e lack of tactile sensitivity in all ter- erates like a pendulum and can be (Fi~
ily c
sistance necessary in the power minal devices makes triggering with a snapped forward using a forceful hu-
stroke, yet "feather" the paddle, re- tllei
prosthesis a safety concern and a meral flexion. The elasticity of the Ski
I
ducing resistance during recovery. questionable practice. Hand causes the pole to rebound to its
Curved paddles and flat paddle decon
In all cases, modifications to fire- original configuration. The Ski 2 (Fig-
signs have been tried; however, de- Ad~
arms should not be performed by the ure 37) is a prosthetic device for hold-
con
pending on the stroke employed, the prosthetic manufacturing facility un- ing a ski pole iliat can be cable oper-
curved paddle has the tendency to
Thi
less personnel are certified in the gun- ated much like a voluntary-closing
elai
submarine and cause a loss of stroke sm iili trade. A certified gunsmith, prehensor. Humeral flexion tightens
volume. Another design, the Swim piv·
qualified and knowledgeable in fire- the cable, causing the pole to pivot for-
of ,
Fin (Figure 35), allows for a flexible arms, should be contracted to modify ward for a pole plant. An elastic bias
paddle design without a prosthesis for guns for use with a prosthesis. returns the pole to its retracted posi-
the
persons with shorter limbs. This sys- tion. Both devices require the removal
Snow Skiing (Alpine and gui
tem is convenient and less costly than of the standard ski pole grip. The Ski 2
Nordic) (Tl
a custom swimming prosthesis. allows for easy pole installation and
cia
Using a roll-on silicone or similar Snow skiing involves upper limb ac- removal, unlike the Ski Hand, which
Sta
liner in any swimming prosthesis can tivity for balance and ski pole control. requires the pole to be force fit into ilie tio
help suspension. Additionally, a pros- The biomechanics involved include hand.
thesis that places the flexible swim- humeral flexion, extension, abduc-
ming paddle closer to the end of the tion, and adduction. Elbow flexion Cameras and Photography,
residual limb will provide the user and wrist flexion and extension can Musical Instrument Adapters,
Pool and Billiards As
with better control. also be involved. A prosthetic device
fo1
needs to be able to adapt to a ski pole. The primary prosthetic objectives for
Other Specialized Activities pb
The ability to easily disconnect from these activities include positive attach- ac.
Firearms Handling (Rifle and the ski pole is useful when ski lifts ment of accessories, stable mounting,
Pistol Shooting) must be boarded. Alpine skiing uses and angular adjustment. The Amp-U-
Certain firearms, such as pistols, can poles primarily for balance, while Pod (TRS Inc) (Figure 38) is a simple
be safely handled with a voluntary- Nordic skiing usually requires poles accessory that adapts to any camera
closing prehensor or an externally for propulsion. equipped with a tripod receiver
powered prosthesis. Because safety is Two manufactured ski devices are mount. The device is a lockable ball-
the primary objective and concern, currently available. The Ski Hand/ and-socket adapter on which the cam-
the prehensor or hand is used for Fishing Hand (Hosmer Dorrance) era is mo unted directly to the end of
gripping and/or stabilizing the pistol, (Figure 36) is available in several sizes. the prosthesis. The Amp-U-Pod facil-
not for triggering. Rifles and shotguns It is a simple prosthetic device that al- itates focusing, meter adjustments,
typically require modification for safe lows the ski pole to fit into a hole in and film changing, while providing a
handling and control. The forea rm of the flexible rubber hand. The pole op- stable mounting platform for filming.

Figure 39 Guitar adaptor accessory. Figure 40 Violin adaptor accessory. Figure 41 Drum Stick Adaptor. (Courtesy
(Courtesy of TRS Inc, Boulder, CO.) (Courtesy of TRS Inc, Boulder, CO.) of TRS Inc, Boulder, CO.)
Musical instrument accessories are formance. Careful assessment of the

specific to the instrument involved, patient's capabilities, requirements,
but a lockable ball-and-socket mount and desires is necessary to ensure a
ory. can provide an adjustable platform on more successful outcome, and assess-
which to attach musical instrument ment of tlie biomechanical demands
holders. Guitar picks and violin bows of the activity provides insight into
(Figures 39 and 40) can be more eas- possible prosthetic solutions. Success-
be
ily controlled with a prosthesis using fully duplicating tliose biomechanical
hu-
these types of adapters. motions required by the activity en-
Ski
Playing the drums requires a more hances performance using a prosthe-
> its
complex adapter. The Drum Stick sis. Safety is also an integral concern Figure 42 Hust ler pool/billiards accessory.
=ig- (Courtesy of TRS Inc, Boulder, CO.)
Adapter (TRS Inc) (Figure 41) is a and needs to be factored into the
>ld-
commercially available alternative. prosthetic equation.
>er-
This accessory holds the stick under A variety of commercially available
;ing
elastic tension while allowing it to and custom accessories have been de- References
:ens 1. Radocy B: Upper-ext remity prosthet-
pivot. The user can d11plicate a variety veloped for persons missing one or
for- ics: Considerations and designs for
of drumming techniques. both hands. Prosthetic aids and acces-
bias sories or modifications to sports and sports and recreation. Clin Prosthet
Pool and billiards require pros-
osi- Orthot 1987;11 :131-153.
thetic stability, as well as flexibility in recreational equipment open the
)val 2. Radocy B: Upper-limb prosthetic ad-
guiding the pool cue. The Hustler doors to successful, competitive, two-
ki 2 aptations for sports and recreation, in
(TRS Inc) (Figure 42) is a commer- handed performance in activities
and Bowker JH, Michael JW (eds): Atlas of
cially available option that provides a ranging from archery to windsurfing.
1ich Limb Prosthetics: Surgical, Prosthetic,
stable and versatile mount for posi- Provision of a well-designed pros- and Rehabilitation Principles, ed 2.
Ithe
tioning and controlling the cue. thesis wiili specialized terminal de- Rosemont, IL, American Academy of
vices will enable the upper limb ampu- Orthopaedic Surgeons, 2002, pp 325-
tee to participate in a broad range of 344. (Originally published by Mosby-
Summary normal recreational and sporting ac- Year Book, 1992.)
rs,
As conswner demand has developed tivities. In many cases, performance is 3. Radocy B, Beiswenger W: A high per-
for specialized sports prostheses, em- currently limited not by ilie available forma11ce, variable suspension, tran-
; for
phasis has been placed on the goal of prosthetic technology but by the phys- sradial prosthesis. J Prosthet Orthot
ach-
achieving competitive bimanual per- ical capabilities of tlie participants. 1995;7:65-67.
cing,
>-U-
nple
nera
!iver
ball-
:am-
id of
'acil-
ents,
ng a
1ing.

Manufacturer Contact Information

Fillauer, Inc TRS,Inc
2710 Amnicola Hwy. 3090 Sterling Circle, Studio A
Chattanooga, TN 37406 Boulder, CO 80301-2338
(800) 251-6398 (303) 444-4720
www.fillauer.com Fax (303) 444-5372
Hosmer Dorrance Corp 800-279-1865
561 Division St. www.oandp.com/trs
Campbell, CA 95008 T/Wr ight Archery
800-827-0070 PO Box 1541
hosmer@hosmer.com Lethbridge, Alberta, Canada, TLJ 4K3
Texas Assistive Devices, LLC
9483 County Road 628
Brazoria, TX 77422
(979) 798-1185
www.n-abler.org
ln1
Lim
nica
Resources suq
cro,
Access to Recreation Inc Handicapped Scuba Association (HSA) International
tion
Equipment for the Physically Challenged (catalog) www.hsascuba .com
www.accesstr.com 196>
Keeping Fit (booklet) refii
Active Living (magazine) Healthy Lifestyles for Abilities Unlimited of a
Today's Amputees www.oandp.com/abilities corr
PO Box 2660
Little League Challenger Division (A special division for spn
Niagra Falls, NY 14302
tel: (800) 725-7 136 children with disabilities) the
fax: (905) 957-6017 www.littleleague.org tali t
active Iiv@aol .com sup
National Amputee Golf Association (NAGA)
www.activelivingmagazine.com pre·
info@nagagolf.org
tho
America's Athletes With Disabilities National Federation of State High School dru
www.americasath letes.orrg Associations Rule Books ma·
www.nfhs.org
Amputee Coalition of America (ACA) sigr
www.amputee-coa Iition. org National Mobility Equipment Dealers ject
Amputee Golfer (magazine) Association (NMEDA) an
www.nagagolf.org/Magazine www.nmeda.org spi1
National Sports Center for the Disabled thi:
Assistive driving resources. lti Mo tio11 1998;8. pla
www.nscd.org
Association of Driver Educators for the Disabled (ADED) wic
www.driver-ed .org Orthotic & Prosthetic Assistance Fund, Inc pat
opaf@opfund .org 1m,
CHAMP, The War Amps Child Amputee Program
CHAMP Newsletter wil
Palaestra (magazine of adapted physical education)
www.waramps.ca tis~
www.palaestra.com
sor
Department of Veterans Affairs Prosthetic and Sensory Physically Challenged Bowhunters of America, Inc wil
Aids Service (PCBA) me
Mailing Code 113 www.pcba-inc.org lirr
Washington, DC 20420
(202) 273-8515 Sports Anyone? (booklet)
Fax (202) 273-9110 American Orthotic and Prosthetic Association (AOPA) Sta
info@aopanet.org go:
Disabled Sports/USA (OS/USA) liv
www.dsusa.org United Foundation for Disabled Archers (UFFDA)
bowtwang@runestone.net
at
tni

Future Developments: Hand
Transplantation
Christopher H. Allan, MD
Introduction
Limb transplantation has been tech- plants have now been performed in eral months after the French tianS-
nically feasible for many years. T he several centers worldwide, with tlms plant, in January 1999, a team in Lou-
surgical techniques allowing for mi- far a 100% survival rate of the al- isville, Kentucky, performed the first
crovascular anastomoses and coapta- lografted limbs in the present era. An hand transplant in the United States.
tion of nerves were developed in the earlier transplant in 1964 failed, and Strategies for patient selection and
1960s. These techniques have been the first patient in t11e modern era of evaluation, surgical procedure, immu-
refined greatly, such that replantatjon hand transplantation ( 1998 to the nosuppressive regimen, and postoper-
of amputated hands and digits is now present) requested elective removal of ative rehabilitation were similar for
commonplace. The obstacle to wide- his transplant. One other transplanted the two groups.
for spread use of limb transplantation is hand has since been removed as well . Hand transplants have since been
the potential for morbidity and mor- performed in China, Italy,Austria, and
tality due to the long-term immuno- several other countries.2 At least 18
suppression presently required to
History
such procedures have now been w1-
prevent rejection of the allograft, al- The first hand transplant was re- dertaken, six for bil ateral hand loss,
though new drugs and techniques of ported in 1964 in Ecuador and sur- and return of function is being closely
drug delivery are under study and vived for 2 weeks before rejection morutored. 4 Because the risks of long-
may red uce thls barrier. There are occmred, despite a regimen of immu- term immw10suppression are believed
significant ethical concerns over sub- nosuppressive medications consistent to be so great, it is difficult to make the
jecting patients to these risks to treat with knowledge at that time. Substan- case for single limb allograft trans-
a non-life-threatening condition. De- tial scientific progress in in1munosup- plant; some smgeons believe that the
spite these concerns, at the time of pression has since been made. 1' 2 The procedure should be reserved for pa-
this writing, at least 18 hand trans- next attempt at hand transplantation tients with loss of both hands. A sur-
plants have been performed world- took place in 1998 in Lyons, France, vey of the audience at the 2001 meet-
wide since 1998. This cohort of and involved a 48-year-old man who ing of the American Society for
patients represents an ongoing exper- had lost hjs right forearm and hand to
Surgery of the Hand revealed that
imental group, lessons from which a circular saw injury in 1984, at which
more than 90% of surgeons in atten-
will guide the future of composite time he underwent replantation.3 The
dance would consider the procedure
tissue allogratl transplantation. In original replanted limb was electively
for themselves in the event of bilateral
some modified form, tl1is procedure amputated for lack of function in
hand loss, whereas fewer than 5%
wiJJ lil<ely change forever our treat- 1989. Nine years later, transplantation
would wish to undergo hand trans-
ment options for the patient with of a midforearm-level allograft upper
plantation for loss of a single hand.
limb loss. lin1b from a 41-year-old brain-dead
While prostheses remain the gold male donor was successful, resulting
)PA) standard for replacing lost limbs, the in a viable graft. After several episodes Patient Selection and
goal of replacing the limb with a new of rejection, the patient eventually
opted to discontinue immunosup-
Preoperative Testing
living one has become a reality, allbeit
a highly controversial one. Successful pressive therapy and requested that The selection criter,ia used by the Lou-
rnidforearm-Jevel upper limb trans- the allografted hand be removed. Sev- isville group2 ' 5 included patient age

via the brachial artery, and cooled. suppressive therapy reginJen, which is toxic
Excess skin is removed, and arteries not used when using a patient's own tivel'.
(radial, ulnar, and anterior in- limb. ous
terosseous), veins (cephalic and ba- with
silic), nerves (median, ulnar, and ra- rolui
dial sensory), and tendons (dorsal
lmmunosuppression exp a
ru1d palmar forearm muscles or ten- The required immunosuppressive risk
dons) are then identified and tagged therapy and its associated toxicity lipid
for later suture. Dorsal and palmar (nephrotox:icity, myeloproliferative can
incisions are made on the recipient and lymphoid tumors) are the main rive
limb under tourniquet control, a nd obstacles to widespread use of limb nola
the corresponding structures are transplantation.7 Transplanted or- row-
identified. gans, including hands, are recognized sym
Figure 1 Stabilizing donor hand and The radius and ulna are cut trans- as foreign by host T cells. T and B cell fecti
forearm to recipient forearm bones. (© versely on both donor and recipient lines clonally expand and in their ac- kine
Copyright Jewish Hospital; Kleinert, Kutz limbs and stabilized with compression tivated fOl"m invade the graft and de- ropl
and Associates Hand Care Center; and 1
plates and screws (Figure 1). With the stroy it. Various steps in this process dysl
University of Louisville, Louisville, KY.
Photo by John Lair.) Louisville patient, a pronation con- are targeted by several immunosup- Ii
tracture required release of the prona- pressive medicines. One risk with all ano1
tor teres. With the Lyons patient, au- of these medicines is that the host's inm
between 18 and 65 years, overall good togenous bone grafting was necessary. ability to recognize and attack other accc
health, amputation at the wrist level, Following skeletal stabilization, vascu- threats to the host, such as infectious the
and human immtmovirus-negative lar anastomoses (arteries first) are organisms or neoplastic cells, is im- tion
and hepatitis B-negative status. Pre- performed with No. 8-0 or 9-0 suture. paired. For this reason, immunosup- inte
operative workup included H LA typ- T he French team reported 12.5 hours pression carries a risk of infection or nee,
ing, cytomegalovirus and Epstein-Barr of ischemic time from donor death to malignancy, both of which can trar
serology, electromyography (EMG) arterial anastomosis; the Louisville threaten quality of life and can result sup
and angiography of the involved limb, team reported "cold ischemic time" of in patient death. gral
and limb and chest radiographs. Other 310 minutes. Next, the nerves are re- Hand allografts comprise many tain
teams 6 have included MRl of the in- approximated, folJowed by muscle different tissue types with different nos
volved limb. Psychiatric and psycho- and tendon units. Tendon ends are antigenicities, which can also compli- see1
logical evaluation and testing are re- woven through muscle when length cate therapy. Any successful regimen etic
quired as well. An advocate not allows, approximated end to end, or must prevent rejection of all these tis- (
associated with the transplant team is joined using a Pulvertaft weave tech- sue types. two
selected by the patient, and a team of nique.6 Tendon grafts (taken from the Animal studies have shown that of c
health care professionals in the pa- patient's feet) and transfers were used single-agent protocols (ie, one drug qui
tient's home area is established for with the first Louisville transplant be- designed to reduce toxicity) work only sysI
close follow-up after surgery. In- cause of the patient's shortened and if used in high doses for the rest of the or i
formed consent is obtained in writing atrophic forearm musculature. Ten- patient's life, and risks of respiratory hos
and is filmed. don transfers comprised brachioradi- and other complications are corre- by
In each of the first two hand trans- alis to flexor carpi radialis, extensor spondingly high . Therapy with muJti- int,
plants (Lyons, France; Louisville, Ken- carpi ulnaris to extensor pollicis lon- ple agents can be as successful with ho~
tucky, United States) the donor and gus, and extensor carpi radialis brevis lower doses and lower toxicities. due
recipient had mismatches at all six to extensor cligitorum communis. In work with a swine model, Lee leti
HLA alleles. Donors were adult males Other tendons were repaired directly, an d associates8 reported that complete do1
matched with recipients for bone size with the middle, ring, and little finger major histocompatibility complex inv
and skin tone. 2 profundus tendons conjoined. Autog- matching can decrease requirements rep
enous skin grafting was used at the for immunosuppression, allowing hi11
time of wound closure in each of the long-term graft survival after only me
Surgical Procedure first two transplant patients. The op- 12 days of cyclosporin-A. ate
The surgical procedures followed by erated limb was then splinted and Presently, hand transplant patients ma
both groups have been described in postoperative monitoring begun in a are treated with both an induction ea1
detail and are quite similar.3 •5 The do- similar fashion to tl1at followed after phase, characterized by higher doses po
nor Limb is removed through or near replantation (anticoagulation, anti- of medications, and a maintenance lor
the elbow joint, perfused with Univer- biotics, frequent vascular checks). The phase of immunosuppression. Com-
sity of Wisconsin transplant solution principal difference was the immuno- bined therapies are used to minimize ea~

Chapter 27: Future Developments: Hand Transplantation 341
I lS toxicity of any one agent and to effec- lishing chimerism. The donor T cells Monofilament testing reported at
WU tively block T cell activation at vari- used to establish mixed chimerism are 14 months showed "diminished or loss
ous steps. Corticosteroids are paired immunocompetent and can identify of protective sensibility!' The fust
with cyclosporin-A or FK-506 (tac- and respond to foreign tissue. In hand transplant at Lyons showed sen-
rolimus), which prevent T cell clonal GVHD, donor T cells can react to re- sibility intact to deep pressure only. No
I expansion against the transplant but cipient tissues as foreign; this is par- data were reported for the first two
;ive risk renal toxicity, hypertension, dys- ticularly a risk when the recipient's Chinese transplants. The Louisville
:ity lipidemia, and diabetes mellitus. They own immune system is suppressed, as patients could distinguish hot and
tive can also be paired with antiprolifera- is often done to protect a transplanted cold in the palm of the transplanted
a in tive agents (azathioprine or mycopb e- organ. Results of tl1e graft cells react- band by 20 weeks. EMG at
mb nolate mofetil), which risk bone mar- ing against host tissues can include 6 months demonstrated potentials in
or- row suppression or gastrointestinal skin rash, peeling or blistering skin, the radial and ulnar nerves only. EMG
zed symptoms and cytomegalovirus in- inflammation of the stomach and in- at 12 months showed the ulnar lum-
cell fection. Corticosteroids inhibit cyto- testines witl1 resulting nausea and bricals were innervated, as was the
ac- kine production by T cells and mac- cramping, and liver involvement with adductor pollicis, although this mus-
de- rophages but can cause hypertension, resultant jaundice. In studies in a rat cle demonstrated only 3/5 motor
cess dyslipidemia, and glucose intolerance. hindlimb model, GVHD did not de- power on clinical examination. By
up- In addition to these risks, cost is velop until levels of donor T cell chi- 11 months, the patient could use his
l all another factor complicating the use of merism exceeded 50%.7 In most pro- transplanted hand to help tie shoes
)St's immunotherapy. Immunosuppression tocols, the level of chimerism and pick up small objects.2
ther accounts for approximately 80% of achieved bas ranged from 2% to 10%, In September 2003, hand surgeon
LOUS the present cost of hand transplanta- suggesting low risk of GVHD. 1 and transplantation researcher W.P.
im- tion. For these reasons, there is great These strategies are not clinically Andrew Lee, MD, reported observa-
;up- interest in reducing or eliminating the applicable yet, but they hold promise tions made during his recent visit to
1 or need for these costly toxic drugs in for reducing requirements for the im- six hand transplant centers world-
can transplantation. The goal of immuno- munosuppressive protocols presently wide.4 He noted that most patients
:sult suppression-host tolerance of the in use. Given the present risks associ- were hospitalized for several months
grafted part-can theoretically be at- ated with these protocols, the future after transplantation surgery and un-
1any tained in other ways than with immu- of hand transplantation may well rest derwent daily hand therapy for 6 to
:rent nosuppression. The pathway that on the success or failure of efforts in 12 months. All but one of the
1pli- seems rnost promising is hematopoi- this area. 12 11 patients he met and examined had
men etic chimerism. had rejection episodes, and many had
: tis- Chimerism is the coexistence of major complications (eg, skin necro-
two genetically different populations
Functional Results sis, osteomyelitis) requiring periods
that of cells in the same animal. 1 This re- The work done by the Louisville of prolonged hospitalization. All pa-
drug quires depletion of the host's immune group when preparing to embark on tients continued to receive systemic
only system via anti-T cell cytotoxic drugs their program of hand transplanta- immunosuppressive medications. His
.f the or irradiation (during which time the tion suggested that the expected func- examinations of these 11 patients
1tory host is at risk for infection), followed tional outcome might parallel that showed that most had recovered pro-
orre- by grafting of donor bone marrow seen after hand replantation. Not sur- tective sensation, but only about half
1ulti- into the recipient. The mechanism of prisingly, sensibility and intrinsic could localize sensation to a specific
with host tolerance to donor graft thus in- hand muscle function (which rely on digit. Only two showed any evidence
duced is not clear but may involve de- nerve regeneration) recover less well of reinnervation of the intrinsic mus-
, Lee letion of thymus T cells targeting the than extrinsic muscle function (which cles of the transplanted hand. Like
1plete donor. 9 Various strategies are being relies on tendon repairs or grafts), other reports, his findings suggest
aplex investigated. One laboratory recently both after replantation and after that the functional outcome after
nents reported delayed rejection in a rat transplant. Thus, restoration of grip, hand transplantation is similar to that
,wing hindlimb transplant model when chi- for example, exceeds that of fine ma- seen after hand replantation, but that
only meric donor limb allografts were cre- nipulation. Still, overall results of re- it comes at a much higher cost in
ated through removal of donor bone plantation exceed those of amputa- terms of band therapy and pharma-
tients marrow and replacement with recipi- tion and prosthesis use. Early results cotherapy.
1ction ent bone marrow. 10 Some authors re- suggest tl1at the same is true after
doses port that chimerism need not be life- hand transplantation. 13 ' 14
Future Possibilities
aance long to induce lasting tolerance. 11 The Louisville group reported that
Com- The risk of graft versus host dis- a Tinel's sign developed in the first pa- The growing field of tissue engineer-
.imize ease (GVHD) is present when estab- tient's fingertips after 6 months. ing has as its goal the combining of a

scaffold, multipotent cells, and appro- Summary 7. Kann BR, Hewitt CW: Composite tis-
priate cytokines to "bllild" living tissue (hand) allotranspla11tation: Are we
sues.15 Use of host mesenchymal stem Hand transplantation may be viewed ready? Plast Reconstr Surg 2001; 107:
cells or other cell types leads to a con- as what some surgeons call "a proce- 1060- 1065.
struct comprising these cells and their d ure in search of an indication," if only 8. Lee WP, Rubin JP, Bourget JL, et al:
offspring, inhabiting a scaffold of ex- because of t he toxicity of present im- Tolerance to limb tissue allografts be-
munosuppressive regimens. The tech- tween swine matched for major histo-
tracellular matrix components pro-
n ical aspects of the procedure com- compatibility complex antigens. Plast
duced by these autogenous cells to Reconstr Surg 2001;107:1482-1492.
bine knowledge already developed in
replace the original scaffold . In this 9. Manilay JO, Pearson DA, Sergio JJ,
prior transplantation and extremity
way, replacement body parts might be Swenson KG, Sykes M: Intrathymic
surgical disciplines. Function of the al-
constructed that are host-derived and deletion of alloreactive T cells in
lograft, while poor regardi ng sensibil-
not seen as foreign by host immune mixed bone marrow chimeras pre-
ity, is clearly better than a prosthesis.
defenses. pared with a nonmyeloablative condi-
With more than 1 million persons in tioning regimen. Transplantation 1998;
Hands are quite complex, with
the United States alone living with an 66:96-102.
multiple tissue types and functions,
amputation, the demand for fjmb 10. Lee WP, Butler PE, Randolph MA,
and represent an extreme test of tis-
transplantation would likely be great if Yaremchuk MJ: Donor modification
sue engineering principles. Creating a
the procedw·e and its associated med- leads to. prolonged survival of limb
scaffold to mimic any one of the com- ical treatment were made safe and allografts. Plast Reconstr Surg 2001; 108:
ponents of a hand may seem straight- The
widely available. 17 Work on inducing 1235- 1241.
forward, but combining tissue- has
tolerance will help solve this problem 11. Bourget JL, Mathes DW, Nielsen GP, et
engineered tendons moving tissue- al: Tolerance to musculoskeletal al- of J
if chronic immunosuppression is ren-
engineered bones and join ts fed by lografts with transient lymphocyte nee1
dered wmecessary. Finally, regenera-
tissue-engineered vessels an d given tive healing and tissue engineering chimerism in min iature swine. pro:
sensibility by tissue-engineered nerves may contribute to this area as well. Transplantation 2001;7 l :851-856. alit)
is a daunting task. One strategy used Ha11d transplru1tation is an exciting 12. Brenner MJ, Tung TH, Jensen JN, fill
in vascular grafts recognizes that the Mackinnon SE: The spectrum of com- cific
development holding great promise. It
plications of immunosuppression: ls the
perfect scaffold may be the part itself. is fascinating to speculate on the form
the time right for hand transplanta· (2)
Cadaver arteries have been decellular- this chapter will take in the next edition? J Bone Joint Sttrg Am 2002;84:
ized, removing donor material and tion of this text. by
1861-1870.
leaving the organ ized collagen scaf- ton,
13. Graham B, Adkins P, Tsai TM, Firrell J,
fold behind. This scaffold is then Mat
"seeded" with autogenous cells, which
References Breidenbach WC: Major replantation
tion
versus revision ampu tation and pros-
populate the graft in cultme and lead I. Siemionow M, Ozer K: Advances in thetic fitting in tl1e upper extremity: A area
composite tissue allograft transplanta- late functional outcomes study. J Hand
to a l iving replacement part compati-
tion as related to the hand and upper Surg {Am] 1998;23:783-791.
ble with the recipient. In canine stud-
extremity. J Hand Surg [Am} 2002;27:
ies such tissue-engineered grafts have 14. Breidenbach WC IIl, Tobin GR II,
565-580.
survived and been shown to be ftmc- Gorantla VS, Gonzalez RN, Granger
2. Cendales LC, Breidenbach WC Ill: DK: A position statement in support
tional for as long as 6 months. 16 Hand transplantation. Hand Clin of hand transplantation. J H.and Surg
Man ipulating the ma11y tissues in a 2001;17:499-510. {A m] 2002;27:760-770.
hand in a similar manner may not be 3. Dubernard JM, Owen E, Herzberg G, 15. Musgrave DS, Fu FH, Huard J: Gene
feasible; for example, decell ularization et al: Human hand allograft: Report therapy and tissue engineering in or-
of skin (the most immunogenic of the on first 6 months. Lancet 1999;353: thopaedic surgery. J Am Acad Orthop
tiss ues in a hand transplant) has thus 1315-1320. Surg 2002;10:6-15.
far been limited to the dermis. 4. Amadio PC: What's new in hand sur- 16. Wilson GJ, Courtman DW, Klement P,
Lee and associates 10 add ressed the gery. J Bone Join t Surg Am 2004;86:442- Lee JM, Yeger J: Acellular matrix: A
bone ma rrow component of the al- 448. biomaterials approach for coronary
lograft, generally an early target of 5. Jones Jv\l, Gruber SA, Barker JH, Bre- artery bypass and heart valve replace-
host immune response. Slowing, but idenbach WC: Successful hand trans- ment. Ann Thome Surg 1995;60(suppl
plantation: One-year follow-up. Louis- 2):S353-S358.
not p reventing, rejection was shown
ville Hand Transplant Team. N Engl J 17. Dillingham TR, Pezzin LE, Mackenzie
in a rat vascularized limb t issue trans- Med 2000;343:468-473. EJ: Limb amputation and limb defi-
plantation model wherein allergenic
6. Lanzetta M, Dubernard JM, Owen ER, ciency: Epidemiology and recen t
bone marrow was replaced w ith host et al: Surgical planning of human trends in the United States. South
marrow, leading to a chimeric al- hand transplantation. Transplant Proc Med J 2002;95:875-883. Figu
lograft. 2001;33:683. Con·

we
New Developments in Upper Limb
Prosthetics
O-
st Hans Diett PhD
di-
198;
n
Introduction
108: The field of upper limb prosthetics overview of current approaches to re- concept of Nishihara and associates
bas held great interest for generations search and development. (K Nishihara et al, Glasgow, Scotland,
P, et unpublished data presented at the In-
of prosthetists, scientists, and engi-
neers who have worked to make their ternational Society of Prosthetists and
Prosthetic Hands 011hotists [ISPO] World Congress,
progressive concepts and dreams a re-
ality. However, only concepts that ful- The field of hand prosthetics con- 2001).
fill three criteria have prevailed, spe- stantly struggles with the challenge of
fulfilling two basically incompatible Control Options
om- cifically ( l ) successful integration into
Ts the movement scheme of the patient, requirements: providing the best pos- Although the kinematics of currently
3- sible cosmetic replacement for a lost available hand systems may not have
(2) reliability, and (3) manageability
limb and achieving maximal func- changed much, significant progress
by the prosthetist (D Atkins, Hous-
tionality. As a result, research in the has been made in control options to
ton, TX, unp ublished data, 1995).
:eU J, field focuses on the development of help the amputee operate these de-
Many technical and scientific institu-
ion prosthetic hands that strive to imitate vices with greater ease and precision.
ros- tions presently support }"Ork in this
the natural hand as closely as possible Multiple control options are now
ty: A area. This chapter presents a general available, allowing better customiza-
and the development of prehensors
'-land tion of the prosthetic system to the de-
that are optimized to suit a given
function . mands of the individual user and nu-
merous adjustments for fine-tuning of
;er
ort
Externally Powered the controls. Using a computer, the
Prosthetic Hands prosthetist can mod ify various param-
:urg
eters of every component integrated
Kinematics
into the prosthesis (H Dietl, PhD,
me The classic construction of most Glasgow, Scotland, unpublished data
or- prosthetic hands is based on forceps
hop presented at the ISPO World Con-
kinematics, in which the thumb and gress, 2001) .
fi nger face each other. This type of State-of-the-art hands now have
ent P,
hand has only one degree of freedom. integrated sensors that reduce tl1e us-
A
The advantage of this type of hand is er's need to concentrate on control-
iry
lace- its robust construction; its disadvan- ling the grasping action.2 For exam-
uppl tages are its unnatural motion and ple, on -board sensors for hand
functional limitations in grasp geom- control can signal when to adj ust
.enzie etry. Nevertheless, some of the newest grasping force (both magnitude and
.efi- developments continue to incorpo- direction), opening width, and speed
rate tlus kinematics concept. Exam- of movemen t. 3
ples include the new Motion Control Different types of sensors are used.
Figure 1 M otion Contro l Hand (M otion Hand1 (Motion Control, Salt Lake For example, force measurement is
Contro l, Salt Lake Cit y, UT). City, UT) (Figure 1) and the hand usually based on strain gauge sensors

are
total
prO)I
vent
thot
suffi
for
this
com
that
Figure 4 Pincer-grasp mechanism of the
Karlsruhe hand.
patt
fing
Figure 3 Mechanical structure of the tho1
Karlsruhe hand. 1m1tate the grasp kinematics of a fing
sound hand as closely as possible. The con
advantage of this principle is that the due
in a more frequent use of the hand fingers curl around objects better, so imp
functions. less grip force is required. UnJike the can:
One alternative to the widely used pincer grasp, which has onJy one de- at
Figure 2 Transcarpal hand (Otto Bock
HealthCare, Vienna, Austria). pincer-type grasping styJe is the Elec- gree of freedom, the anthropomor- pro
trohand 2000 for Children 13 (Otto phic hand has additionaJ degrees of acti
Bock HealthCare). In this hand, a freedom, making various grasping bee,
polycentric mechanism coordinates patterns possible, including a power pie~
or force-sensitive resistors. 4 '5 For
the movement of the fingers and grasp and lateral or key pinch. gre<
touch and slip detection, Kyberd and
thumb, improving grasping geometry
Chapell 6 use a combined optical-
and resulting in more lifelike finger The Karlsruhe Project phi,
acoustical sensor. TriaJs with piezo-
movement. Typical desktop activities One innovative new concept is being Sou
electric sensors, 4 as well as sensors
are easier to perform and require less explored at the Research Center in tho
based on the magnetic Hall effect, have
compensatory arm movement. The Karlsruhe, Germany16 (S Schulz, CH fon
also been conducted. 7 These sensors
limited durability and elasticity of Pylatiuk, Glasgow, Scotland, unpub- har
can serve as the signal sources for feed -
contemporary materials used for cos- lished data presented at the ISPO ing
back systems. Electrical· stimuJation
metic covers, such as polyvinyl chlo- World Congress, 2001). Hydraulic ac- for
has proved to be most promising for ride and silicone, have discow·aged tuators flex and extend the finger inti
force feedback. 8 However, work re- more widespread use of this concept. sen
joints and the wrist joint. Each finger
mains to eliminate the interference be- However, because this concept has has three joints, which correspond to
tween the electromyographic (EMG) proved to be beneficial to the patient, attt
the metacarpophalangeaJ joint, the
signals and the feedback stimulation it is likely to be incorporated into the pre
proximal interphalangeal joint, and
puJse. Some groups h ave experi- next generation of prosthetic hands, Ho
the distal interphalangeal joint (Fig-
mented with temperature feedback. 9 replacing the classic pincer-grasp ki- ure 3). The base joint of the thumb me
Better functionality for the patient nematics. allows movement in three planes, re- the
could result in a secondary benefit. A There is significant interest in de- sulting in several grasp patterns. The 1101
group of German psychologists .re- veloping powered components for wrist also allows rotation in all the
ported that increasing prosthetic fw1e- amputation levels distal to the wrist. planes.
tion correlates with a reduction in Some research designs for long resid- The actuators are flexible tubuJar Dr
phantom pain. 10- 12 These authors the- ual limbs have an electromechanical structures that bridge the joints; joint Mc
orize that a functional prosthesis that drive in the fingers . 14 Currently, one flexion is caused by inflation and disuse
includes a feedback mechanism commercially available electrome- tention of the flexible chambers. Pres- tor
should significantly reduce phantom chanical hand allows fitting to mid- sure and fluid flow are generated by a res
pain. metacarpal amputation levels while hydraulic micropump positioned in of
The improved quality of hand con- offering reasonable cosmesis 15 (Figure the metacarpal area of the hand, to- al,
trols combined with increased battery 2). gether with the electric power source da1
capacities allows faster hand move- and the microvalves. This mechanism Co
ments. Patient trials with the recently The Anthropomorphic Hand allows various grasp patterns (Figure SOJ
launched SensorHand Speed (Otto Another alternative to the classic 4) and therefore represents the closest wli
Bock HealthCare, Vienna Austria) in- pincer-grasp geometry .is the anthro- approximation of the natural hand to an
pomorphic hand, which attempts to date. Because most of the elements du
dicate that the increased speed results

Chapter 28: New Developments in Upper Limb Prosthetics 345
are made of lightweight plastics, the

total weight of the mechanism is a p-
proximately the same as that of a con-
ventional lightweight prosthesis. Al-
though this design still lacks a
sufficient number of control inputs
for the various degrees of freedom,
this disadvantage is partially over-
come by a hjerarchical control system
that produces predefined movement
the
patterns. The maximum force at the
fingertips achieved so far is 12 N. Al-
though the adaptability of the flexible
f a fingers combined with the soft sili-
Figure 6 Electronic terminal device (Mo-
rhe cone glove that covers the hand re- Figure 5 Lite Touch hand (TRS Inc, Boul- tion Control, Salt Lake City, UT).
the duces the grip force required, some der, CO).
I so important activities of daily living
the cannot be performed with this hand. the potential to stimulate new interest
be back-driven, so items grasped rein the traditional technique of muscle
de- at thls time. If this new concept
main secure in the fingers. The major cineplasties. This could create a re-
1or- proves to be feasible for performing
, of shortcomings of ultrasonic motors are newed demand for body-powered
activities of daily living, then it will
poor efficiency and the need for high prosthetic hands optimized for cine-
,ing become essential to find new princi-
,wer ples for controlling the multiple de- voltage, both of which result in more plasty control, as occmred in the years
grees of freedom it offers. rapid drain of the batteries. following World Wax U when cine-
Another ongoing anthropomor- Power systems using hydraulic ac- plasties were more commonly per-
phic hand project is Kyberd's tuators are used by the Karlsruhe formed.22
eing Southampton Hand 17 •18 (Oxford Or- group and by Instituto Nazionale Assi-
rm thopaedic Engineering Centre, Ox- curazione contro gli lnfortuni sul Externally Powered Hooks
CH ford, England) . The drive for this Lavoro (INAIL) in Rome, Italy. !NAIL Several styles of externally powered
Jub- hand is conventionally operated, us- uses iliis system for a powered elbow. hooks have established their useful-
ing direct-current motors and cables A hydraulic micropump is the actua- ness. The fundamental requirement
SPO
for actuation. This project focuses on tion force for both the hand drive and in these types of prostheses is robust-
: ac-
intelligent control using integrated tl1e elbow drive. ness, which eliminates complex an-
nger
.nger sensors. 19 tluopomorphic features. In the fu-
Body-Powered Prosthetic
1d to All anthropomorphic hand projects ture, sensors will be integrated into
the attempt to create a functional hand Hands powered hook terminal devices, as has
and prosthesis with improved cosmesis. Unfortunately, only limited progress already been done in some electric
(Fig- However, no project has been com- has been made in improving body- hands. Waterproof electric hooks
tumb mercially successful to date because powered prosthetic hands. The main have recently been developed and will
s, re- the materials currently available can- shortcoming of these devices is their expand the range of electrical tenni-
. The not withstand the strain imposed by poor efficiency, caused in large part by nal devices for performing activities
1 all these kinds of hand mechanisms. the resistance of the protective glove of daily living (Figure 6).
that covers tlle mechanism. Most of
bular Drive Mechanisms the energy tllat the user puts into tlle Mechanical Hooks
joint Most commercial hand designs still device is lost as friction . Herder21 re- Mechanical hooks are the most com-
d dis· use conventional direct-current mo- ported some innovative concepts to monly used of all terminal devices. A
Pres· tors to power the hand. However, two address tllis concern by the use of wide variety of styles is available, but
i by a research groups are exploring the use "rolling links." The efficiency problem only a few are used frequently. Many
ed in of ultrasonic motors20 (K Nishihara et has been overcome with the design of innovative designs for voluntaxy-
d, to- al, Glasgow, Scotland, unpublished the Lite Touch Hand (TRS Inc, Boul- closing devices are available for both
:ource data presented at the ISPO World der, CO), a compromise between cos- pediatric patients and adults. Also, for
anism Congress, 2001). The benefits of ultra- metic design and hook functionality the first time in decades, new designs
Figure sonic motors are high motor torq11e, (Figure 5). The findings of Weiss and for voluntary-opening devices are be-
:losest which allows a reduction in the weight associates, 11 with respect to the role of ing released commercially, including
rnd to and size of the transmission, and re- biofeedback-controlled prosthetics in an energy-optimized two-load hook
,ments duced noise. Also, these motors cannot the reduction of phantom pain, has tllat produces nearly constant grip

binec
tern
the i
be m
For I
direc
and
rep la
arnp1
Figure 8 Electronic elbow prototype, for I
forearm assembly (Otto Bock HealthCare, curn
Vienna, Austria). Figure 9 Electronic elbow prototype,
Roni
drive unit (Otto Bock HealthCare, Vienna,
Austria). pub!
Figure 7 Two-load hook (Otto Bock Worl
HealthCare, Vienna, Austria). permit more dynamic control of B
body-powered elbows with reduced locking mechanism. Elbow flexion sea re
effort by the patient. and extension are achieved by a com· n ity
plex drive consisting of a brushless theti
Electrically Powered direct-current motor, a gear train that
(TO
Elbows allows continuous gear reduction, and
on t
Innovations in electrically powered an electronic servomechanism that
func
elbows include programmable con- adjusts the gear reduction ratio (Fig-
tion
ure 9). For energy efficiency, the drive
trols, improved adjustability, and in - tien1
is supported by an AFB mechanism
creased battery capacity. Patient com- den:
that counterbalances the weight of the
pliance will significantly improve if com
forearm, wrist, and terminal device,
these control schemes can be better tern
thus reducing the demand on the el-
integrated into the body movement of s
bow motor. The servomechanism dis-
the patient so that the prosthetic arm nen·
engages the gear train automatically
movements are less robot-like. One
for an energy-efficient free arm but
approach is to create devices in which
swing. Position and force sensors pro- allo·
at least two degrees of freedom are
vide inputs for the control of this de- thre
contro lled simultaneously. Typically,
vice. A myoelectric arm using this sys- nat~
the prehensor is controlled by myo-
tem can go from extension to full a C(
signals, whereas the elbow is con-
elbow flexion in 0.5 seconds when cep1
trolled by some additional input, such
nothing is being held in the terminal
as a force sensor, that is integrated
device and actively lift 6 kg of weight
Figure 10 Edinburgh Modular Arm into a harness. The logical next step is
(Bioengineering Centre, Edinburgh, Scot- the application of extended physio- in approximately 6 seconds. Si!
land). logical proprioception (EPP), a con- fo
cept advocated by Doubler and Complete Electronic Cc
Ch ildress 23 in 1984. However, to im-
force over a wide range of open ing Arm Systems
widths (Figure 7) .
plement EPP would require an elbow M)
drive with greater speed and force Some research centers aJe developing
Ne,
than is currently available. With the complete electronic arm systems. In
tha
Elbows response time available in today's el- addition to having a powered prehen·
elec
Body-Powered and Hybrid bows, the patien t would complain sor, wrist, and elbow joint, the shoul-
der joint is also powered in these de· ere;
that the artificial arm is delaying the
Elbows signs. In the prototype developed by ele<
movement.
Many new components that can be Elbow designs are now being ex- Gow and associates, 24 the movement so11
operated by a variety of harness- plored to facilitate the implementa- of the shoulder joint is reduced to one tro
based control options are now avail- tion of EPP. One example is an exper- degree of freedom in the sagittal tio1
able, as are programmable electronic imental elbow based on the ErgoAnn plane, the prehensor is an anth ropo· pre
controls. Innovative solutions such family of prosthetic elbows (Otto morphic hand, and tl1e electrome· tel,
as the Automatic Forearm Bal- Bock Healthcare) (Figure 8) . In this chanical actuators are modular, which Sec
ance13 (AFB) and electronic locks design, the elbow axis has an electric allows different assemblies to be corn· at 1

bined (Figure 10). Although the sys- Body Movement

tern is designed as a complete arm, It has been common practice for cen-
the inruvidual components can also turies to use a harness to capture the
be used for lower level amputations. user's body movement to both control
for example, each finger contains a and power a prosthesis. Recently,
direct-current motor and a gear train many new electronic controls that can
and can therefore be used for finger be operated by small body movements
replacement as well as for metacarpal have become commercially available.
amputation levels. A prosthetic hand For example, a microprocessor-
for metacarpal amputation levels is controlled linear transducer incorpo-
currently in clinical testing (JR rated into a lightweight harness can be
type, Figure 11 ProDigit hand derived from
Ronald et al, Glasgow, Scotland, un- used to supplement myoelectric in-
mna, Edinburgh Modular Arm project (Bioengi-
published data presented at the ISPO puts or to replace a missing myoelec- neering Centre, Edinburgh, Scotland).
World Congress, 2001) (Figure 11). tric input.
Based on the findings of British re-
:xion search teams, the European Commu-
com- Contact Forces
nity funded the Totally Modular Pros-
.bless thetic Arm with High Workability Contact forces generated by the resid-
I that ual limb have long been used to con-
(TOMPAW) project, which focused
1, and trol prostl1etic functions. One com-
on the modularity aspects, optimized
that mon application of this control
functionality, cosmesis, and optimiza-
(Fig- option uses microswitches, as in the
tion for use with osseointegrated pa-
drive case of the initial fittings of the Edin-
tients. Bergomed AB (Vadstena, Swe-
mism burgh Modular Arm (B10engineeri11g
den) is finishing the concept for a
of the Centre, Edinburgh, Scotland). The
commercially available product sys-
.evice, typical "on-off" microswitch provides
he el- tem (Figure 12).
Scharer25 uses standard compo- single-speed (digital) control of the
n dis-
prosthesis, analogous to the power
tically nents for the elbow and the prehensor
window button in an automobile.
arm but has designed a shoulder joint that
By using Force Sensing Resistors,
s pro- allows spherical motion by means of Figure 12 Anthropometric hand (Ber-
variable-speed (proportional) control
us de- three actuators. Control signals origi-
can be achieved because the resistance
gomed AB, Vadstena, Sweden).
lis sys- nate from three EMG electrodes using
o full is proportional to the contact pres-
a control scheme based on the con-
when sure. Proportional control is analo-
cept of a neural network.
rminal gous to the accelerator pedal ill an au- Implantable Sensors
weight tomobile, where increased pressure Little progress has been made in de-
translates into increased speed.
Signal Acquisition veloping implantable devices to con-
To avoid damage to this kind of trol an artificial limb. Current re-
for Prosthesis sensor, good protection against mois- search has been focused on two
,ic Control ture is necessary. Researchers at Rut- primary approaches: (1) implantable
gers University have designed a pneu- myoelectrodes, which would lead to a
Myoelectric Signals matic sensor consisting of a pad made better differentiation of muscle
~loping
:ms. In New electrodes are being developed of closed-cell foam and a connected groups, and (2) direct neural cou-
,rehen- that will be much less sensitive to electronic pressure sensor that they pling, which would add neural feed-
shoul- electromagnetic interference and in- claim can reliably detect movement of back.
.ese decrease the performance reliability of a single tendon in the residual limb. T he potential patient group for
iped by electronic prostheses. For example, This would allow the independent implantable electronic devices is
vement some commercially available elec- control of each finger of an anthropo- rather small; therefore, definitive an-
l to one trodes improve common mode rejec- morphic hand. Prototypes of such swers have been difficult to obtain.
sagittal tion, which significantly reduces such sensors have been successfully applied Researchers are attempting to apply
thropo- problems as interference by cellular to test fittings in which an anthropo- the knowledge acquired from the field
ctrome- telephones (PH Kampas, Glasgow, morphic hand with an RC-servo drive of functional electrical stimulation to
r, which Scotland, unpublished data presented (servo drive used in radio-controlled the field of prosthetic limbs 27 (B An-
be com· at the ISPO World Congress, 2001) . model cars) for each finger is used. 26 drews et al, Glasgow, Scotland, un-

ever, donning and doffing a prosthesis a

published data presented at the ISPO Prosthesis Ii
World Congress, 2001) . that incorporates the EMG sensors is
Adjustment complicated for the user. n
Another disadvantage of methods 3
Sophisticated controls require precise
Controls 5. (
monitoring of the fitting and training that modify existing commercial lin-
Most widely used controls are still v
procedures. Many software-based ers is the increased risk of electro-
based on proportional relationships b
tools are now commercially available magnetic interference from the cable
between the EMG signal amplitudes, I.
for this purpose. Animated Prosthet- connections between the preamplifi-
from the contraction of the involved 6. J<
ics (Greensboro, NC) offers a system ers and the skin contact elements. For
t
muscle groups, and the intended ac- that allows wireless programming and example, Millier and associates 36 ex-
:a
tion of the prosthetic component- adjustment of the prosthesis by a per- tended the surface of standard Otto r
such as speed of movement, magni- sonal digital assistant. This type of Bock electrodes and equipped the 9
tude of grip force , or position. 1 system is very convenient for the pa- liner with stainless-steel rivets for 7.}
Closed-loop controls like the tient and makes the adjustment pro- conducting EMG signals. Problems s
Southampton Adaptive Manipulation cess easier because the patient is not occurred in clinical use as a result of c
Scheme (SAMS) (Oxford Ortho- physically tethered to the computer. electromagnetic disturbances created l
paedic Engineering Centre) princi- Otto Bock offers an adjustment sys- by the movement between the elec- 8. \
ple17 or the Otto Bock Dynamic tem for different levels of complexity. trode surface and the rivet surface. A \
Mode Control (DMC) principle (R In most cases, only a few adjustments solution to these problems will be an f
Kaitan, unpublished data presented at are required, making the software important advance because patient
Weltkongress Orthopadie und Reha- simple to use. When necessary, an ex- comfort can be improved significantly 9. I
Technik, 1994) feed back information pert system can be invoked that is by use of today's elastomer liner tech-
internally, resulting in more precise much more complex but provides nu- nologies.
and reliable user control. merous adjustments to refine the con-
trol algorithms for more difficult
The SUVA grasp stabilization sys-
fittings (H Dietl, PhD, Glasgow, Scot-
Conclusion 10. I
tem (Schweizerische Unfall Ver- I
sicherungs Anstalt-Swiss Insurance land, unpublished data presented at Progress in arm prostheses remains
the ISPO World Congress, 200 1). evolutionary rather than revolution-
Agency, Lucerne, Switzerland) is an
ary. Regretfully, it may take years be-
additional control loop that activates
fore a new concept becomes a com-
once an object has been grasped. 3 A Sockets and l l. ~
mercially available component that
sensor measures the force vector be-
Suspension can make its way into daily clinical
tween the hand and the grasped ob-
practice. The limited budgets for re-
ject and monitors changes in this vec- The small population of upper limb
amputees and the complexity of the search and development in this field,
tor. If the change indicates a potential compared with that for other techno-
risk of dropping the item, the grip components that must be integrated
into their prostheses make research logically driven industries, and the 12.'
force is increased to a level that stabi- demanding reliability requirements
into this area very challenging. No
lizes the grasp. This mechanism al- for prosthetic limbs make research in
specific tools are available for
lows the user to pay less attention to this area singularly challenging.
computer-aided socket design of up-
the prosthetic device.
per limb prostheses. Most upper limb
Another approach uses the com-
bined EMG signals from electrodes or
sockets use materials and design con- References 13.
cepts that have proved successful for
electrode arrays that are applied to 1. Sears HH, Shaperman J: Proportional
the larger population of lower limb
the residual limb. These multiple sig- myoelectric hand control: An evalua-
amputees.32 "34 However, considerable tion. Am I Phys Med Rehabil 1991;70:
nals are processed by a neural network is being done to improve liner 20-28. 14.
work that generates the output for the technology for myoelectric prosthe- 2. Chappell PH, Kyberd PJ: Prehensile
simultaneous control of all degrees of ses. Daly35 inserts metal contacts into control of a hand prosthesis by a mi-
freedom of a prosthetic arm. Labora- roll-on silicone socket liners and con- crocontroller. J Biomed Eng 1991;13:
tory results have been promising, 2s-3o nects them to the preamplifiers of a 363-369.
especially from projects that combine myoelectric system. Motion Control 3. Puchhammer G: Der taktile Rutsch-
neural networks with fuzzy logic.31 now offers contacts and cables that sensor: Integration miniaturisierter
However, these control systems are are specifically designed for use with Sensorik i11 einer Myo-Hand.
not yet sufficiently reliable to inte- such elastomeric liners. Grope! inte- Orthopadie-Tehnik 1999;7:564-569.
grate this type of control in prosthe- grates the cables and skin contacts in 4. Tura A, Lambert C, Davalli A, Sac-
ses for activities of daily living. custom-made liners directly. How- chetti R: Experimental development of

is a sensory control system for an upper metacarpals./ Prost Orthot 2001; 14: 25. Scharer C: Mikroprozessorsteuerungfiir
is limb myoelectric prosthesis with cos- 26-3 I. eine Armprothese mit trainierbarer Befehl-
metic covering. J Rehabil Res Dev 1998; 15. Dietl H, Grope! W: Versorgu ng nach serkennung. Zurich, Switzerland, Swiss
35:14-26. Teilhandampu tationen mit myoelek- Federal Institute ofTeclrnology, 1993.
:is
5. Okuno R, Yoshida M, Akazawa K: De- trischen Komponenten. Orthopadie- Dissertation.
n-
velop ment of biometric prosthetic Technik 200 1;1:21-23. 26. Craelius W, Abboudi RL, Newby NA:
o- Control of a multi-fingered prosthetic
band controlled by electromyogram. 16. Schulz S, Pylatiuk CH, Bretthauer G: A
>le hand. Proceedings of ICORR'99.
IEEE 1996;9:103-108. New ultralight anthropomorphic
6- hand. Proceedings of the international Stanford, CA, Stanford University,
6. Kyberd PJ, Chappell PH: Character.iza-
or Conference on Robotics and Automation. 1999, pp 255-259.
tio n of an optical and acoustic touch
:x- and slip sensor for autonomo us ma- New Jersey, IEEE, 2001, pp 2437-244 l. 27. Herberts P, Kadefors R, Kaiser E, et al:
ct:o nipulation. Meas Sci Technol 1992;3:: 17. Kyberd PJ, ChappeJJ PH: The Implantation of micro-circuits for
he 969-975. Southampton Hand: An intelligent myoelectric controls of prostheses.
for 7. Kyberd PJ, Chappell PH: A force sen- myoelectric prosthesis. / Rehabil Res J Bone Joint Surg Br L997;50:780-791.
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of on the Hall effect. Meas Sci Technol 18. Kyberd PJ, Evans M, te Winkel ST: An wavelet-based continuous classifica-
ted 1993;4:281-287. intelligent anthropomorphic hand tion scheme for multifunction myo-
ec- with automatic grasp. Robotica 1998; electric control. IEEE 2001;48:302-311 .
8. Wang G, Zhang X, Zhang J, Gruver
.A 16:531-536. 29. Huang HP, Chen CY: Development of
WA: Gripping fo rce sensory feedback
an for a myoelectrically controlled fore - 19. Kyberd PJ, M ustapha N, Carnegie F, a myoelectric discrimination system
arm prosthesis. IEEE 1995;1:501 -504. Chappell PH: A clinical experience fo r a multi-degree prosthetic hand.
ent
with hierarchically controlled myo- IEEE Robotics and Automation Society
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electric hand prosthesis with vibro- Proceedings. 1999, pp 2392-2397.
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vancement ofAssistive Technology. Am- CC: Development of neural network
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speed control of a travelling wave ul- using single-chi p microcontroller.
JO. Flor H, Elbert T, Knecht S, et al:
trasonic motor for prosthetic hands. Biomed Eng 1993;5:24-30.
Phantom-limb pain as a perceptual
1ins Proceedings of the IFAC Conference on
31 . Chan FHY, Yang YS, Lam FK, Zhang
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.on- YT, Parker PA: Fuzzy EMG classifica-
following arm an1putation. Nature many, 2000, pp 401-406.
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11. Weiss TH, Miltner WHR, Adler T, et Conception and Design of Statically Bal-
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al: Decrease in phantom limb pain anced Spring Mechanisms. Delft, The
1ical associa ted with p rosthesis-induced sign options. Phys Med Rehabil Clin N
Netherlands, Delft Unjversity of Tech-
· re- increased use of an amputation stump Am 2000;11:627-638.
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22. Weir RF: A century of the Sauerbruch-
lDO· 131-134. management of the upper limb defi-
Lebsche-Vanghetti muscle cineplasty:
the 12. Weiss TH, Miltner WHR: Die Bedeu- cient child. Phys Med Rehabil 2000;14:
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9th World Congress of the International
:h in alitat von Prothesen filr die Entwick- Societ;, for Prosthetics and Orthotics. 34. Uellendahl JE: Upper extremity myo-
lung von Phantomschmerz und Amsterdam, T he Netherlands, 1998, elect ric prosthetics. Phys Med Rehabil
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Tecfmik 2003;1: 11 -15. 23. Doubler JA, Childress DS: An analysis 35. Daly W: Clinical application of roll-on
13. Dietl H: Tendenzen in der Entwick- of extended physiological propriocep- sleeves for myoelectrically controlled
onal lung von Prothesen fur die obere Ex- tion as a prosthesis control technique. transradial and transhu meral prosthe-
lua- tremitat. Orthopadie-Technik 1997;2: J Rehabil Res Dev 1984;21:5-18. ses. J Prosth Orthot 2000;12:88-91.
.70: 126-132. 24. Gow DJ, Douglas W, Geggie C, Mon- 36. Miiller N, Lehmann A, Vietz W, Zapfe
14. Weir RF, Grahn EC, Duff SD: A new teith E, Stewart D: The development J: Silikonliner fur myoelektrische Unter-
ile externally powered, myoelectrically of the Edinburgh Modular Arm sys- armprothesen. Orthopadie-Technik
mi- controlled prosthesis for persons with tem. Proc Instn Mech Engrs 2000; 10:876-879.
13: partial-hand amputations at the 2001;215(part H):291-298.
ch-
ter
,9.
c-
1ent of

The
Lower Limb
In·
Wal
a St
tior
tanc
desi
mai
Sup
fun
UTII
ene
con
joir
latt·
intf
pos
acti
ate,
pla,
the
gra
for,
is I
Stai
vid
sur
vise
car
fac
Wei
rea
lati
ch,
ap1
on,
Op]
the
int
Normal Gait
Jacquelin Perry, MD
Introduction
Walking relies on each limb repeating muscle action based on the mechanics
a sequence of integrated joint mo- of the limb. 1' 4' 5 Joint power is calcu-
tions under muscle control to simul- lated using the product of moment
taneously advance the body along the and joint velocity to differentiate the
desired line of progression and to intervals of muscle energy generation
maintain weight-bearing stability. 1 or absorption. 6
Superimposed on these two basic
functions are actions that absorb the
impact of limb loading and minimize Divisions of the Gait
12 35 50 62
energy cost. These functions are ac- Cycle % Gait cycle (end
01
stance
complished by the interplay of free
Each sequence of lower limb action, phase)
joint mobility and muscle action; the
from initial floor contact by one foot
latter is selective in both timing and Figure 1 Vertical ground-reaction force
to the next iJ1Stant of initial floor con- during the stance phase of one gait cycle.
intensity.2
tact by the same foot, is called a gait F0 = Impact peak force. F1 = loading re-
Walking is also an interplay of op-
cycle, or stride. The instant of floor sponse peak force. F2 = Preswing push-off
posing forces. Muscles generate the
contact by the foot is designated the peak force. (Reproduced with permission
active force needed to initiate, acceler- from Powers CM, Heino JG, Rao S, Perry J:
ate, and decelerate the rate of dis- beginning of the gait cycle because it
The influence of patellofemoral pain on
placement of the limb. The masses of is a consistent, conspicuous event that lower limb loading during gait. Clin
the limb segments, influenced by is readily visualized or measmed. Biomech 1999;14:722-728.)
gravity and inertia, present opposing Some call this onset event "heel
forces, the most prominent of w!hich strike;' but because either the heel or
forefoot may touch the floor first, I events into functional patterns of the
is the ground-reaction force during limb and identifies the phases of gait.
stance phase (Figure 1). Because indi- prefer the term initial contact (IC) .2 A
vidual muscle force cannot be mea- step, which is one half of a gait cycle
Floor Contact Pattern
sured directly, a system has been de- (gc), consists of the events that occur
from IC by one limb to IC by the op- The simplest subdivision of the gait
vised by which muscle force values
posite limb, ie, right IC to left IC or cycle divides the cycle into two peri-
can be deduced from the measurable
factors of limb dimensions, body vice versa. ods: the period of floor contact
weight, joint motion, and ground- To facilitate differentiation of the (stance phase) and the period of mid-
reaction forces. 3 The resulting calcu- numerous events occmring within a air limb advancement (swing phase),
lated values identify the external me- gait cycle, two basic systems for sub- which is initiated by " toe-off." The
chanical moments of gait. Then, by dividing the cycle have been devised. gait cycle is divided into 100 percent-
applying the principle that a force in The floor contact pattern was the first age points, with 0% representing the
one direction generates an equal and approach. Later attempts to better ex- moment when the foot first contacts
opposite force in the resisting object, plain the interplay of the asynchro- the ground and 100% representing
the external moments are translated nous joint motions resulted in the the next IC. The timing of events
into internal moments to identify second approach, which groups the within the gait cycle is indicated by

354 Section III: The Lower Limb
TA'E
A
Tas~
Tas~
(F
Tas~
(F
Tasl
a•
Midstance Terminal stance

Initial contact Loading response
Figure 2 Weight acceptance gait phases showing limb posture Figure 3 SLS gait phases showing limb posture and critical events
and critical events (reference limb shaded). A, Initial contact (con- (reference limb shaded): midstance (left, foot flat, ankle neutral;
tact by heel). B, Loading response (shock-absorbing knee flexion). and right, foot flat, ankle dorsiflexed, center of body mass over seq
(Adapted with permission from Perry J: Phases of gait, in Perry J toe) and terminal stance (heel rise, ankle dorsiflexed, center of
body mass beyond toe). (Adapted with permission from Perry J: the
(ed): Gait Analysis: Normal and Pathological Function. Thorofare,
NJ, SLACK, 1992, pp 12-14.) Phases of gait, in Perry J (ed): Gait Analysis: Normal and Patholog- obj
ical Function. Thorofare, NJ, SLACK, 1992, pp 12-14.) ter:
alt!
pla
stance, during which period weight is
ne<
transferred from the trailing to the an,
leading foot. The average duration of Ea,
double-limb stance is 12% of the gait ica
cycle. When one foot lifts for swing, fur
the function of the other limb ate
changes to single-limb support (SLS). thE
The average duration of SLS is 38% wa
gc. At the end of stance, both limbs
are again in con tact with the ground
as weight is transferred from the now- fl
trailing foot to the lead foot. This in- A
terval is called terminal stance and
represents 12% gc. m,
Preswing Initial swing Midswing Terminal swing 5)
Phases of Gait
pl.
The second system of subdividing the pr
Figure 4 Swing limb advancement showing limb posture and critical events (reference
limb shaded): preswing (forefoot contact, ankle plantar flexed, knee flexed), initial gait cycle is based on phases of gait. te1
swing (peak knee flexion, swing foot opposite stance limb), midswing (foot clear, tibia Researchers who observed the comfo,
vertical, peak hip f lexion). and terminal swing (hip f lexed, knee extended, ankle dorsi- plex interaction of hip, knee, and an- by
flexed). (Adapted with permission from Perry J: Phases of gait, in Perry J (ed): Gait Anal- kle motion identified a total of eight
ysis: Normal and Pathological Function. Thorofare, NJ, SLACK, 7992, pp 12-14.)
or
limb patterns that displayed a unique to
functional significance. These are the a11
giving the percentage at which they slower speeds lengthens stance time phases of gait. The functions of these
occw-; eg, for an event that occurs one and shortens swing time proportion- eight gait phases combine to accom- \J\
third of the way through the gait cy- ally. Conversely, the faster the walking plish three tasks:2 weight acceptance, N.
cle, the indication would be 33% gc. speed, the shorter the stance phase. SLS, and swing limb advancement Tl
At the average normal velocity of The stance phase can be further (Figures 2 through 4). Each of these er
approximately 80 m/min, stance phase subdivided into periods of double- tasks meets several objectives required lo
occupies 62% of the gait cycle and and single-limb support. 7 Each step for normal gait. This information is is
swing phase involves 38%. Walking at begins with initial double-limb summarized in Table 1. ni

Chapter 29: Normal Gait 355
TABLE 1 Tasks and Phases of Gait
Task Phases of Gait Objectives

Task A: Weight acceptance • Init ial contact (initiates the heel rocker for Limb stabilization to support the fal l of body
(Figure 2) progression and impact reduction) weight
• Loadin g response (knee flexion for shock Shock absorption
absorption) Preservation of progression / I
Task B: Single-limb support • Midstance (forward roll of limb over t he Progression

(Figure 3) supporting foot)
• Terminal stance (advancement of t he body beyond Weight-bearing stability
the supporting foot)
Task C: Swing limb • Preswing (transition from stance to swing) Foot clearance of the floor
advancement (Figure 4) • Initial swing (floor clearance as limb advances) Forward swing of th e limb
• Midswing (final thigh advancement)
• Term in al swing (final reach for step length, Preparation of t he limb for stance
prepa ration for stance)
ents
tral; Each individual joint performs a rapid ankle plantar flexion (6° by 5% Kinetics
over sequence of motions, which reflects gc). This drops the forefoot toward A small and brief internal dorsiflexor
:r of
ry }:
the actions needed to accomplish the the floor, but forefoot contact is de- moment follows initial heel contact
,log- objectives of gait. T he dominant p at- layed by the onset of ankle dorsiflex- during the first 4% of the gait cycle.
tern of motion is in the sagittal plane, ion. At this point the rounded This indicates activity of the pretibial
although motion does occur in o ther surface of the heel functions as a sup- muscle group to control the falling
planes, including minor rotation porting rocker over which the foot foot. The power identifies th at the
1t is
needed for o ne limb to pass the other and tibia roll forward until the fore- muscle action is eccentric and that it
the
and to help maintain lateral balance. foot contacts the floor (12% gc) . At is most intense at the onset of the
n of Each motion is associated with a ded- the end of the loading response, the motion (0.3 W/kg·m by 3% gc). 6 Pro-
gait icated pattern of muscle control. T he ankle is at neutral and the tibia is ver- gression of the body weight vector
fog, function of each joint is best appreci- tical. over the heel then advances the vector
.imb ated by relating the motion pattern of Two functions are accomplished: anterior to the ankle joint axis and
LS). the joint to the three basic tasks of
(1) The impact of abrupt floor con- initiates a plantar flexion moment.
38% walking.
tact is partially absorbed by the initial Joint power, however, indicates a low
robs
foot drop, and (2) progression is pre- level of generative muscle action. This
,und
Function of the served by the stimu lation of rapid is consistent with concentric pretibial
LOW·
tibial advancement (180°/s) to over- muscle activity moving the ankle to-
; in- Ankle Joint ward dorsiflexion. The late onset of
and come the static posture favored by the
The ankle passes th rough four arcs of electromyographic (EMG) activity in
nearly vertical alignment of the limb.
motion during each gait cycle (Figure the soleus at this time identifies an in-
5), which are alternating periods of Muscle Control terval of antagonistic cocontraction,
plantar flexion and dorsiflexion. The which supports the contradiction .be-
; the The pretibial muscles control the pos-
primary objective of the motion jpat- tween the moment and joint power
gait. ture of the foot throughout weight
tern of the ankle is progression. The data.
:om- acceptance. Already active in swing
foot also contributes to progression
I an- by its sequence of floor contact: heel
to support the foot, the anterior mus- Sing le-Limb Support
:ight cles abruptly increase their intens- Motion
only (0% to 12% gc), foot flat ( 12%
ique ity as body weight is dropped onto From a neutral position at tl1e onset
to 31 % gc), forefoot (3 1% to 62% gc),
: the and swing (62% to 100% gc).2 the heel. The anterior tibialis is of SLS, the a nkle progressively d orsi-
'.hese dominant at 35% of its maxinrnm flexes, attaining 10° of dorsiflexion by
:om- Weight Acceptance manual muscle test electromyography the end of the task. During this arc of
mce, M otion (MMT/EMGmax), whereas the exten - motion the mode of foot support
nent The dominant motion is a brief, but sor digitorwn longus and extensor changes. Midstance is an interval of
:hese critical, arc of plantar flexion fol- hallucis average 20% of MMT/ foot flat support. Combined heel and
.tired lowed by dorsiflexion. Initial contact EMGmax· Pretibial muscle action forefoot floo r contact provides stabil-
rn is is made by the heel with the ankle at ceases when the forefoot contacts the ity as dorsiflexion of the ankle (7° at
neutral. Loading the heel initiates floor (12% gc). 31% gc) advances the center of pres-

sur
stai
hea
rise
do1
ti OJ
the
Task Weight Acceptance Single-Limb Support Swing Limb Advancement foo
Phase IC LR MSt TSt PSw ISw MSw TSw M1

20 Dorsiflexion Th
de:
10 fle:
Motion O-b-~~~~~~-1---~~----l~\r--l-~~-6~ ~ ~---I
(degrees) in
Plontor Flexion
-10 of
UIT
-20
do
Muscle Action sta
(% MMT)
Anlerior libiolis gc;
Extensor digito rum longus
40'
Soleus , - --;:::~ L.-----1.--,,,, de,
sin
Gostrocnemius
lee
Posterior tibiolis th<
Peroneus longus oli
Peroneus brevis an
Flexer digilorum longus le,
Flexer hollucis longus
ca1
tib
15 Ki
10 n
pr·
5 all
Internal Sl
Moment 0 tir
(N·m) (5
-5 pr
de
gr
4 di
3 er
Power 2
(W/kg·m) s,
0 Tl
sv
-1
A bsorb fo
be
Tl
% Gait Cycle 0 12 31 50 62 75 87 100 dj
r,e
Figure 5 Normal ankle reference dat a for motion, muscle action, internal moment, and power are show n in relati on to the t hree tasks
and eight phases of motion. IC = Initial contact, LR = Loading response, MSt = Midstance, TSt = Terminal stance, PSw = Preswing. P,
ISw = Initial swing, MSw = M idswing, TSw = Terminal swing. Column shading indicates phases within t hat task. (Adapted with permis·
sion from The Pathokinesiology Service & The Physical Therapy Department (eds): Observational Gait Analysis. Downey, CA, Los Amigos T
Research & Education Institute, 2001, pp 11-21 .) al

Chapter 29: Normal Ga.it 357
sure to the forefoot. Du1·ing terminal by rapid transfer of body weight to the center of body mass, having ex-
stance, as the rounded metatarsal the other limb. Relief from full body ceeded the limits of stability, has initi-
heads act as a forefoot rocker, the heel weight frees the joints to respond to ated the fall of body weight onto the
rises and the ankle reaches 11° of their trailing alignment. The response leading limb. The early rate of weight
dorsiflexion at 45% gc. The combina- at the ankle is rapid plantar flexion to transfer is indicated by the impact ex-
tion of foot and ankle action advances 18° below neutral. While this motion perienced by the loading heel. A typi-
the center of body mass beyond the· is occurring, the tibia and foot are cal ground-reaction force sample
foot. rolling forward over the point of floor shows 60% of body weight received
contact. At the same tin1e, the point within 20 ms.9 Unloading of the pre-
M uscle Control of support advances beyond the swing limb occurs at the same rate.
The soleus and gastrocnemius mus- transverse axis of the forefoot, thereby
This rapid change in load initiates a
cles control the rate of ankle dorsi- removing the force that has been sta-
sequence of three significant events.
flexion. Both muscles become active bilizing the foot on the floor. The mo-
The external dorsiflexion moment at
in loading response, and the intensity bile metatarsophalangeal (MTP) joint
the ankle is terminated, and this re-
of the action continues to increase becomes the preswing area of sup-
leases the residual gastrocnemius-
until the ankle approaches maximum port. This could be classified as a
soleus muscle energy. With the signif-
dorsiflexion near the end of terminal fourth rocker; its function is to facili -
stance (soleus: 88% of MMT at 43% tate preparation of the limb for icantly unloaded limb presenting only
gc; gastrocnemius: 79% of MMT at swing. a minor antagonistic moment, the re-
40% gc) . Muscle activity then rapidly sidual gastrocnemius-soleus energy,
decreases, terminating by the end of Preswing: Muscle Control now in a concentric mode, initiates
single stance (50% gc).8 The perimal- The source of the energy for this large ankle plantar flex:ion (without EMG
leolar muscles (so named because and rapid arc of ankle plantar flexion stimulation), and the pattern of pre-
they wrap closely around the malle- has been long debated. Neither the swing limb motion begins.
oli) also are commonly identified as soleus nor the gastrocnemius muscle The sin1ultaneous occurrence of a
ankle plantar flexors, but with limited exhibits evidence of EMG activity high internal moment at the onset of
leverage and small mass, they are in- during preswing. The long toe flexors preswing and the rapid rate of ankle
capable of controUing weight-bearing are still active, but they are too small plantar flexion combine to generate a
tibial rotation. to produce a force capable of moving prominent spike of mechanical power.
the limb. Rather than neural control, Although the spike is brief because of
Kinetics the force moving the ankle into plan- quick dissipation of the plantar flex-
The small plantar flexor moment tar flexion is a by-product of the ion moment, the tinllllg identifies it as
present at the onset of SLS continu- rapid curtailment of the strong dorsi- the "push-off force," which initiates
ally increases in intensity throughout flexion moment that developed du.r- forward advancement of the limb.
SLS to reach a peak of 14 N ·m by the ing terminal stance. This releases the
time the other foot contacts the floor final accumulation of soleus muscle Swing: Motion
(50% gc) . This mo1:nent indicates energy (without EMG stimulation ) as
With the onset of toe-off, the ankle
progressively stronger action of the motion rather than static restraint.
begins its final arc of dorsiflexion
dominant plantar flexor muscle Physiologically, this represents a rapid
during initial swing. Neutral align-
group. Calculation of joint power in- change in the mode of muscle con-
ment is reached by the middle of
dicates this muscle action to be en- traction, from eccentric to concentric.
midswing (80% gc) and is maintained
ergy absorbing and eccentric. In clinical terms, this is called "re-
through terminal swing.
bound." The rapid transfer of body
weight also frees the limb to respond Swing: Muscle Control
Swing Limb Advancement to the final soleus output.
The third arc of ankle motion (pre- Ankle dorsiflexion is provided by the
swing, terminal double support) and Preswing: Kinetics anterior tibia.tis and long toe extensor
fourth arc of ankle motion (swing) Two force patterns are generated at muscles, the activity of which begins
both contribute to limb advancement. the ankle during preswing. These are just before toe-off and quickly attains
These two motion patterns have very curtailment of the internal plantar a moderate intensity (30% of MMT).
different mechanics, so they will be flexion moment and the generation of In midswing, once the foot is appro-
reviewed separately. high mechanical power. priately positioned, the activity of
e tasks Floor contact by the lead foot sig- these muscles often temporarily di-
:swing, Preswing: Motion nifies the onset of preswing and that minishes or even ceases; however, the
)ermis-
C\migos The preswing phase is a period of unloading of the trailing limb already intensity increases quickly during ter-
abrupt unloading of the trailing limb is in progress. Forward alignment of minal swing.

358 Section ill: The Lower Limb
Swing: Kinetics Metatarsophalangeal intensity of the medial hamstrings

During the three phases of swing, the Joints (semimembranosus and semitendino-
relatively small mass of the foot (aver- Motion sus) being relatively greater than that
of the quadriceps. The flexor muscle
age, 0.45 kg) is insufficient to produce Heel rise during terminal stance
action then subsides, and the activity
a detectable moment. A brief period phase is accompanied by dorsiflexion
of the quadriceps increases notably in
of power absorption during initial at the MTP joints. The limb is in a
intensity, to 30% of MMT, to stabilize
swing reflects a minor concentric re- trailing position, and the forefoot
the flexed knee for the transfer of
sponse to lift the foot. (metatarsal heads) provides support. body weight.
The forward roll of body weight over
the forefoot both lifts the hindfoot Kinetics
Function of the Foot and diminishes the area of the fore- At the onset of stance, an immediate
Joints foot providing support. The toes are but brief flexor moment occurs (peak:
Only two joints of the foot have suffi- included in the supporting area. Dur- 4 N·m at 3% gc) . Power is generated
ciently large arcs of motion to be iso- ing terminal stance phase, the MTP that, when related to the accompany-
lated during gait. These are the subta- joints dorsiflex 20°; this extension ing EMG activity, indicates initial
lar joint and the MTP joints. may reach 55° during preswing. dominance of knee flexor muscula-
ture to prevent knee hyperextension;
Subtalar Joint Muscle Control
however, this period is characterized
Motion Resistance to the dorsiflexion mo- by cocontraction of the quadriceps
ment imposed by heel rise is provided and hamstrings. By 5% of tile gait cy-
An early, brief arc of calcaneal ever-
by the toe flexor muscles (flexor ha.1- cle, the knee moment develops an ex-
sion (5° at 5% gc) occurs in response
lucis longus and flexor digitorum lon- tensor orientation. Power absorption
to initial contact by the heel and is
gus) and the intrinsic muscles. Stabili- dming t he end of weight acceptance
followed by a slow yield of an addi-
zation of the toes enlarges the a1·ea of indicates that the extensor muscles
tional few degrees through early mid-
forefoot support. The intrinsic mus- are providing an eccentric force to
stance.10 Then, the subtalar joint
cles augment the toe control provided stabilize the passively flexing knee.
gradually reverses toward neutral by
by the long muscles.
early terminal stance. Analysis of the
Single-Limb Support (Arc 2)
motion of the calcaneus shows a per-
Motion
sistent eversion of approximately 2°. Function of the Knee
At the onset of SLS, the knee progres-
During swing, the forefoot registers
The knee performs four arcs of mo- sively reduces its flexion throughout
slight inversion.
tion during a gait cycle. A sequence of midstance and early terminal stance.
flexion followed by extension occurs Maximwn extension (3° of flexion ) is
Muscle Control
during both the stance and swing reached at 36% gc and maintained for
Eversion following heel contact stim- phases (Figure 6). a short time, until 42% gc, when the
ulates a prompt response by the mus-
knee reverses its motion, toward flex-
cles that control inversion. The ante- Weight Acceptance (Arc 1) ion.
rior tibialis, already active during Motion
swing, immediately increases its in- In response to the heel rocker rotating Muscle Control
tensity, but it ceases when its dorsi- the t ibia forward, the knee rapidly Continuation of the prior quadriceps
flexion action terminates. The poste- flexes from a relatively stable position action at a lesser intensity actively ex-
rior tibialis also responds promptly, of 5° flexion at initial contact to 18° at tends the knee. By 20% gc, however,
and its activity persists throughout the end of the loading response (12% the EMG for all four of the vasti mus-
the stance phase. In addition, its in- gc). T his motion is the major source cles ceases. Further knee e:x.1:ension is
tensity increases with heel rise. Lateral of shock absorption to lessen the a passive reaction to remote forces
restraint of potential subtalar inver- stress of rapid limb loading, but the that advance the body over the sup-
sion is provided by the peroneus lon- final position does not allow weight porting foot.
gus and peroneus brevis muscles. bearing without dynamic control.
Subtalar control during swing phase Kinetics
is provided by the dorsiflexor mus- Muscle Control Although the extensor moment,
cles. The anterior tibialis inverts the Throughout weight acceptance, the which peaked earlier, rapidly declines
forefoot, and tl1e extensor digitorum hamstrings and quadriceps act syner- to zero by the middle of midstance,
longus and peroneus tertius muscles gistically, exchanging dominance as the accompanying generative power
provide eversion. The result is bal- needed. At initial contact, protective indicates that a brief interval of con-
anced dorsiflexion. flexion is emphasized, w ith the EMG centric extensor muscle action occurs

gs
:>-
at
:le
ty
Task Weight Acceptance Single-Limb Support Swing Limb Advancement
in
ze MSw TSw
of Phase IC LR MSt TSt PSw ISw
60
50
He Motion 40
3k: (degrees)
:ed 30
1y- 20
:ial 10
.la- 0 +-~~--1~~~~--+~~~~-t-~~~+--~~-1-~~-+~~-"'1
:>n;
ied Muscle Action
(% MMT)
eps Quadriceps
ey-
Semimembronosus ~ - - - - ·
ex-
ion Biceps (long head)
nee Semitendinosus
des Popliteus
to
Grocilis
Redus Femoris
2)
Biceps (short head)
Sartorius
res-
LOUt 10
nee. Internal 5
1) is Moment
l for
the (N·m) oJ--J(___-l-~-.c----+-~~~::::~~~--=+-~ ~
rlex- -5 Flexor
Generate
eeps
r ex-
ever, Power
nus- (W/kg·m)
m is -2 Absorb
)fees
sup-
% Gait Cycle O 12 31 50 62 75 87 100
Figure 6 Normal knee reference data for motion, muscle action, internal moment, and power are shown in relation to the three tasks
nent,
and eight phases of motion. IC= Initial contact, LR = Loading response, MSt = Midstance, TSt = Terminal stance, PSw = Preswing,
:lines ISw = Initial swing, MSw = Midswing, TSw = Terminal swing. Column shading indicates phases within that task. (Adapted with permis-
anee, sion from The Pathokinesiology Service & The Physical Therapy Department (eds): Observational Gait Analysis. Downey, CA, Los Amigos
,ower Research & Education Institute, 2001, pp 11-21.)
eon-
ecurs

at this time. These data correlate with Fiber alignment implies that the gait, must be considered. 13 Further,
the segment velocity pattern, which popliteus may contribute internal tib- the sagittal axis between the pelvic
shows that the transfer of energy ial rotation to un lock the extended landmarks used in the laboratory for
from the decelerating tibia to the fe- knee. Three muscles contribute dur- gait analysis (the anterior and poste-
mur facilitates knee extension. 11 Con- ing initial swing: the short head of the rior superior iliac spines) tilts down-
tu1Uing anterior displacement of the biceps femoris, tl1e sartorius, and the ward 10° anteriorly from the vertical,
body weight vector introduces a mod- gracilis. resulting in a m easured hip angle be-
erate flex:ion moment, which peaks at Muscle control of the extending tween the thigh and pelvis that is 10°
3 N ·m during terminal stance. The knee involves a synergistic sequence. greater tl1an the angle of tl1e th igh rel-
lack of significant power and EMG First, a reduction of the flexor influ- ative to the reference axis of the labo-
activity at this time indicates that this ence by the gracilis and short head of ratory. During normal gait, the pelvis
is a passive event. the biceps femoris occurs. By the tilts a mere 5°, but during pathologic
middle of midswing, activation of the gait, pelvic deviations can be signifi-
Swing Limb Advancement long hamstru1gs (semimembranosus, cant. Laboratory gait analysis is ori-
{Arcs 3 and 4) long head of the biceps femoris, and ented to calculating hip motion, while
Motion semitendinosus) mtroduces a two- the observing eye follows the thigh.
The knee moves through two large joint whip effect, which aids inhibi- The hip is the focus of the discussion
arcs of motion of similar duration. tion of the forward swing of the thigh presented here.
The first is flexion, to elevate the foot at the hip while also avoiding hyper-
for floor clearance, followed by exten-
extension at the knee. At the onset of Weight Acceptance
terminal swing, the quadriceps mus- {Posture 1)
sion, to complete step length in prep-
cles introduce knee extension. Motion
aration for stance.
Knee flexion is essential for the Kinetics At IC the h ip is flexed 30°, and this
swinging limb to clear the floor. 12 posture is maintained w1til the end of
A small extensor moment is created
Three gait phases are involved: termi- the loading response. Abrupt loadi11g
during preswing despite the relatively
nal stance, preswing, and i11itial of the limb initiates a con tralateral
large arc of knee tlexion (40°). Also,
swing. In terminal stance, knee flex- pelvic drop in tl1e coronal plane,
measurements of the associated
ion is initiated by the center of pres- which reaches 4° by the end of the
power show a prominent peak of en-
sure moving beyond the stable area of loading response. This is noted at the
ergy absorption (1.5 W/kg·m) despite
the forefoot. The pushing action of hip as adduction. The forward pelvic
the absence of significant EMG activ-
the ankle during preswing rapidly in- rotation of 10° is equivalent to the ex-
ity in the knee tlexors. These appar-
creases knee flexion to 40° by toe-off ternal rotation of the hip.
ently inconsistent facts suggest that
(62% gc), which represents two thirds
the rapid knee motion contributes to
of the arc needed for toe clearance. Muscle Control
the power peak.
Finally, an additional 20° is gained Both moment and power are min- Maximum involvement of hip mus-
during initial swing by a combu1ation imal during initial swing and mid- culature occurs during the task of
of active knee and hip flexion. Peak swing. During terminal swing, a mod- weight acceptance. The two primary
tlexion is 60° by 70% gc. est flexor moment and accompanyi ng hip extensors, the adductor magnus
After reaching maximum flexion peak of energy absorption occur. This and the lower gluteus maximus, are
during initial swing, the knee quickly indicates that flexor activity is domi- activated in late terminal swing and
reverses the direction of motion, to- nant in the extensor and flexor mus- quickly increase in intensity, peaking
ward extension, through midswing cle cocontraction that EMG studies at IC (adductor magnus, 40% of
and into late terminal swing. After show occur at this tin1e. MMT; lower gluteus maximus, 25%
reaching zero extension, the knee of MMT). This intensity has dimm-
flexes 2° to 3°. ished by the middle of tl1e task, and
Function of the Hip the action ceases by the end of the
Muscle Control
The hip has just two arcs of motion loading response. The hamstring
Direct muscle control of this large arc during the gait cycle, one of flexion muscles, which begin their action
of knee flexion is subtle, with the and one of extension (Figure 7). In d uring midswing, continue during
source beu1g low-intensity activity addition, two intervals of static pos- Fig
the loading response at a slightly re-
an
(13% to 17% of MMT) of several turil1g supplement this movement. duced u1tensity (semimembranosus, ISv
small muscles. The popliteus is con- Defining hip motion is difficult be- 23% of MMT; long head of the biceps sio
sistently active duril1g the last 5% of cause not only the movement of the femoris, 10% of MMT). Re
terminal stance and during early pre- thigh but also that of the pelvis, Lateral support of the hip by the
swing, but otherwise its timing varies. which may alter its alignment during abductor muscles also is most intense

.er,
vie
for
te-
rn-
:al, Task Weight Acceptance Single-Limb Support Swing Limb Advancement
)e-
l00 Phase IC LR MSt TSt PSw ISw MSw TSw
40
·el-
)O- 30-+-----•
vis
Motion 20
(degrees)
gic 10
ifi- 04--~~--l-~ ~~~...P,...,_~ ~ --l-~~--.,A~~~ l--~~1--~--I
>ri-
. -10
1ile Muse Ie Achon
gh. (% MMD
ion Gluteus moximus, lower
--~~
Adductor magnus
Semimembranosus
Biceps (long head)
Semitendinosus
G luteus medius
this Gluteus maximus, upper
i of
Tensor fascia Iota
ing
Adductor longus 1 - - - -1 - - -- -- -+--- -
era!
Gracilis
me,
the Rectus femoris 1 - - -- 1 -- - -- - - 1 - - - -- - 1 - - -
the Sartorius ~ - - - 1 -- - - -- 1 - - - -- - 1 - - --
Ivie lliacus 1 - - - - 1 - - - - - - - + - - - - - - - 1 - - - - - +
ex-
lO Extensor
5
Interna l
lUS- Moment 01- ~ ~-1-~--.....::::--1-~~ ~-1~~-1-~-=;;;;;ool.--~-l-~---l
of
iary
(N·m) -5
:nus
are -10
and
<ing 2
of
~5% Power o-l,....~~ --l~~---=--_J~~~~-l..'-~~-1-~~~-----~~~---a
nin- (W/kg·m)
and -1
the -2
ring 100
% Gait Cycle 0 12 31 50 62 75 87
tion
ring
, re- Figure 7 Normal hip reference data for motion, muscle action, internal moment, and power are shown in relation to the three tasks
and eight phases of motion. IC= Initial contact, LR = Loading response, MSt = Midstance, TSt = Terminal stance, PSw = Preswing,
>sus, ISw =Initial swing, MSw = Midswing, TSw = Terminal swing. Column shading indicates phases within that task. (Adapted with permis-
ceps sion from The Pathokinesiology Service & The Physical Therapy Department (eds): Observational Gait Analysis. Downey, CA, Los Amigos
Research & Education Institute, 2001, pp 11-21.)
· the
ense

during weight acceptance. 14 The ment during terminal stance and the sistent witll d1e small reduction in hip Pror
mean intensities are moderate, with power calculation showing muscle flexion recorded during this period. limi
the gluteus medius averaging 28% of absorptive action are not consistent serv,
MMT, the upper gluteus maximus av- with the minimal flexor EMG. kle <
eraging 23% of MMT, and the tensor Function of the I-
fascia lata averaging 18% of MMT. Swing Limb Advancement Pelvis ever
(Arc 2, Posture 2) The pelvis follows the swing limb as it resp
Kinetics Motion moves forward . Conversely, the pelvis iJwe
The immediate peak extensor mo- With the onset of preswillg, the hip and
appears to rotate backward relative to
ment (7 N·m at 3% gc) is consistent begills to flex. This action continues ever
the stance limb. At lC, tile weight-
with the moderately strong EMG ac- through initial swillg and early mid- CODI
accepting limb and tlrnt side of the
tivity of the hip extensors, partku- swing. Maximum flexion of 35° is at- the
pelvis are at tile maximum forward
larly that of the adductor magnus tailled at the end of midswing (86% 1
rotation (5°) relative to the center of
muscle. Continuation of a slightly re- gc). Then, duriJ1g terminal swing, the forv
tile body. Forward swing of the con-
duced extensor moment occurs, fool
hip assumes a final posture at 30° of tralateral limb rotates the pelvis to a
which is consistent with the interpre-
flexion. transverse neutral alignment in mid- a st
tation that extensor muscles are sup-
stance. By the end of terminal stance, The
porting the flexed hip. The increasing Muscle Control the weight-bearing side of the pelvis on 1
arc of generative power, which peaks
As tile flexing hip moves tl1rough its is relatively posterior (5°). The pelvis by
at the end of the phase, indicates that
arc, a transfer of control from one set also has a 5° anterior tilt. The abrupt pro
the extensor muscles are contracting
of muscles to another occurs. During transfer of body weight causes a con- velc
concentrically to iJ1itiate active hip
preswing, flexion is provided by two tralateraJ pelvic drop in the coronal adv
extension.
muscles that combine adduction and plane, which is recorded as 4° eleva- and
Single-Limb Support (Arc 1) flexion : the adductor longus (con- tion of the pelvis on tlie stance limb. lim
Motion tracting at its highest intensity, 30% qua
of MMT) and the gracilis, which con- bea
As the contra1ateraJ limb prepares to
tracts at a low intensity (18% of
Function of the Total ion
lift the foot (at 10% gc), the hip be-
gins to extend, an action tliat contin- MMT). The combination of flexion Limb foo
ues throughout midstance and termi- and adduction accompanies the shift Weight Acceptance of I
nal stance. Maximum hyperextension of body weight toward tile contralat- Weight acceptance is the most chal- per
(-15°) is reached at tl1e end of termi- eral limb. During initial swing, lenging task of walkillg (Figure 8). At Sin
nal stance. shortly after toe-off, the iliacus and ma
weight acceptance, approxiJn ately
sartorius become active at a low in- 60% of body weight is almost insta11- fie>
Muscle Control tensity (18% of MMT) and continue taneously dropped onto the forward mu
Contraction of tl1e primary hip ex- through the phase. Also, the gracilis limb. The nearly erect alignment of Syr
tensor muscles has ceased activity, but increases its intensity (to 28% of the lin1b, with the thigh only 20° from bo1
the activity of the medial hamstring MMT) during early initial swing. vertical, favors stability over progres- of
group (the semimembranosus and During termillal swillg, the extensor sion. ten
sem itendinosus) persists into single function of the hamstrillgs actively
terminates hip tlexion. The semi- Initial Contact (0 % gc) Kii
stance. The abductor muscles con-
tinue their activity through most of membranosus (33% of MMT at 88% As tl1e heel contacts tile floor, the hip Fie
midstance and terminal stance. The gc) is more active than the long head is flexed 20°, tl1e knee is extended (5° pe,
semiposterior orientation of these of the biceps femoris and the semi- of flexion ), and the ankle is dorsi- an,
muscles to tl1e hip indicates that they tendinosus (20% of MMT at 98% gc). flexed to neu tral. The heel rocker is act
would contribute some extensor con- set. of
trol. The tensor fascia lata, which has Kinetics of
an anterior alignment, remains active With contralateraJ foot contact signi- Loading Response Co
into ea1·ly terminal stance, providiJ1g a fyillg the onset of preswing, the mag- (0 % to 12% gc) Sill
dynamic limit to extension. nitude of the flexion moment of the The mechanics of the heel rocker fa-
hip declines rapidly. Power calcula- cilitate two functions: preservation of m<
Kinetics tions show, however, that the muscle progression and shock absorption. im
At the onset of siJ1gle stance, the mag- action becomes concentric to advance Loading tile heel illitiates ankle plan- op
nitude of the extensor moment and tl1e thigh. During terminal swing, ex- tar flexion, with a peak foot drop ve- sic
power generation rapidly decline. tensor moment is small and concen- locity of 300°/s, softening the impact ex
Both the development of a flexor mo- tric power is miJ1imal, which is con- of initial floor contact (Figure 1). ra

hip prompt pretibial muscle response

:I. limits the arc to 6° at 5% gc and pre-
serves the heel rocker by initiating an-
kle dorsiflexion .
Heel contact also initiates subtalar
eversion as another shock-absorbing
lS it response. The combined action of the
lvis inverting muscles (anterior tibialis
! to
and posterior tibialis) limits subtalar
;ht- eversion to 5°. This muscle action
the continues until the forefoot contacts
ard the floor.
l" of
The foot and tibia continue rolling
on- forward on the heel rocker until fore-
:o a foot contact occurs (at 12% gc), when
iid- a stable, foot flat posture is attained.
1ce, The energy of the foot rolling forward
lvis on the heel is transmitted to the tibia
:lvis by the contracting pretibial muscles,
propelling the tibia forward at a peak Initial contact Loading response
upt
on- velocity of 180°/s. This rapid tibial
mal advancement initiates knee flexion Figure 8 Total limb function during weight acceptance. Limb posture and critical mus-
!Va- and interrupts the shock of rapid cles for the involved phases are shown. (Adapted with permission from Perry J: Total
limb loading. A prompt increase in limb function, in Perry J (ed): Gait Analysis: Norma l and Pathological Function. Thoro-
1b.
fare, NJ, SLACK, 7992, pp 157-158.)
quadriceps activity preserves weight-
bearing stability by limiting knee flex-
ion to 18°. The early interval of rapid
foot drop also shortens the duration
of the heel rocker, which reduces the
period of peak quadriceps response.
tial-
Simultaneous response by the pri-
. At
mary hip extensors stabilizes the
.tely
ran- flexed hip and, by controlling the fe-
rard mur, also contributes to knee stability.
Synergistic action by the hamstrings
t of
rom both provides circumferential control
res- of the knee a11d augments the hip ex-
tensors.
Kinetics
Floor impact initiates a11 immediate Midstance Terminal stance
hip
(50 peak moment (3% gc) at both the hip
and knee, but the direction of the re- Figure 9 Total limb f unction during SLS. Limb posture and critical muscles for the in-
>!Si- volved phases are shown. (Adapted with permission from Perry J: Total limb function, in
:r is actions differ. At the hip, the moment Perry J (ed): Gait Analysis: Normal and Pathological Function. Thorofare, NJ, SLACK,
of 8 N·m represents the peak response 7992, pp 157-758.)
of the primary hip extensor muscles.
Continuing support is provided by a
smaller extensor moment (5 N·m). the heel rocker. A dorsiflexion mo- Single-Limb Support
At the knee the immediate peak ment at the ankle controls the foo t.
. fa-
moment is a flexor moment, which By the end of weight acceptance, SLS is shown in Figure 9. During this
n of
implies action by the hamstrings to the limb attains a posture of dynainic prolonged period of progression, en-
ion.
oppose potential knee hyperex:ten- stability. The foot is flat and the ankle ergy is conserved as direct muscle
lan-
sion. The moment then reverses, to an is neutral, but there are residual flexor control is replaced with passive con-
ve-
pact extensor moment, in response to the moments at the hip and knee, which trol to maintain knee and hip stability
1). rapid tibial advancement initiated by still require active muscle control. during the last half of the task.

during their prior eccentric activity in A

terminal stance. The resulting rapid thigl
ankle plantar flexion initiates 40° of cont
knee flexion and energizes the limb to mus
swing forward. cus
Several factors contribute to pre- al's ,
swing limb advancement. The posture f]exi
of the limb at the end of terminal reli~
stance is critical: it is in trailing align- fun<
ment, with only the forefoot contacting
ing the floor, while the ankle is maxi- thig
mally dorsiflexed and the hip is at the clea
end of its extensor range. Both tensed cau:
muscle groups are active. The knee flex
has been unlocked as the support area
Preswing Initial swing Midswing Terminal swing of the foot rolls forward beyond the Mi,
center of the metatarsal heads during Wit
Figure 10 Total limb fu nction during swing limb advancement. Limb posture and critical late terminal stance and is free to repor
muscles for the involved phases are shown. (Adapted with permission from Perry J: Total spond. Also, EMG activity in the ing
limb function, in Perry J (ed): Gait Analysis: Normal and Pathological Function. Thoro- popliteus is a constant finding.
fare, NJ, SLACK, 1992, pp 151-158.) res1
The rapid transfer of body weight cor.
to the contra.lateral limb at the onset de,
Midstance (12 % to 31 % gc) tension. Then, as the foot becomes of preswing releases the stored energy ffi l (
At the onset of SLS, the supporting unstable, flexion of the limb slowly in the hip and ankle musculature. A mu
begins. rapid sequence of motion follows. var
area is limited to the dimensions of
Most prominent is the arc of ankle ave
the weight-bearing foot. As the ankle
advances to 5° of dorsiflexion, the
Kinetics plantar flexion. Passive tension stored tib
Throughout SLS, the plantar flexor in the previously active gastrocnemius sw'
body weight vector reaches the fore-
moment at the ankle is accompanied and soleus muscles is released rapidly fle;
foot (metatarsal heads). Graduated
by significant EMG activity of the so- by the fall of body weight onto the
soleus and gastrocnemius action to
leus and gastrocnemius. The increas- contralateral limb. Because there is no
slows the rate of tibial progression to
EMG activity, the release of stored en- Te
48°/s, and the progressional velocity ing intensity of the eccentric action is
ergy is assumed to be the push-off 1()
of the femur is increased to 140°/s by demonstrated by the power pattern,
force that advances the tibia and
the quadriceps, which act concentri- which shows progressively greater en- K11
flexes the knee.
cally at this point. When neutral knee ergy absorption. The plantar flexor tio
Hip flexor control also contributes
extension is reached (by 23% gc), the moment at the ankle is the source of ler
to the initiation of knee flexion . The
quadriceps muscle relaxes. The hip remote knee and hip control. sta
stored flexor energy is released, and
uses this accelerated advancement of qu
Swing Limb Advancement the adductor longus and gracilis mus-
the femur over a slowed tibia as a re- pb
cles, while acting to limit the rate of
mote source of e.xtensor control. Figure 10 illustrates swing limb ad- m:
medial fall, also initiate advancement
vancement. Two modes of limb me- hy
of the thigh from its trailing position.
Terminal Stance (31 % to chanics are involved in this task: for- na
50% gc) ward swing of the foot for step length Initial Swing (62 % to 75% gc) or
Continuing progression of the body and preparation of the limb for Two critical motions are completed K,
weight vector over the anterior fore- stance. during initial swing: knee flexion and
foot significantly increases the inten-
C,
hip flexion . Maximum knee flexion
sity of the EMG activity of the soleus Preswing (50% to 62% gc) in
(60° by 72% gc) lifts the toe for floor
and gastrocnemius muscles. The ac- This final phase of stance is a period ea
clearance. This amount of knee flex-
companying heel rise contributes sig- of double support during which pre- m
ion is required because the trailing
nificantly to the plantar flexor mo- swing is simultaneous with contralat- si:
posture of the lower leg places the
(~
ment. Advancement of the thigh over eral weight acceptance. Rapid forward foot into a toe-down position. The fl,
the relatively stable tibia passively ex- transfer of body weight favors the contributing muscles are the short
tends the knee and hip w1til the end
fc
mechanics of preswing. Unloading of head of the biceps femoris, the sarto-
31
of terminal stance. The tensor fascia the limb releases the energy stored by rius, and the gracilis, all of which
lata may be active to restrain hip ex- the soleus and gastrocnemius muscles contract at low intensities.

in Active hip flexion advances the tensor moment with absorptive 3. Bressler B, Frankel JP: The forces and
>id thigh. This is accomplished by t he power. Thus the hip and ankle mo- movements in the leg dming level
tion is due to active muscle contrac- walking. Trans ASME 1950;72:27-36.
of continued activity of the preswing
to muscles with the addition of the ilia- tion, whereas knee function is passive. 4. Cappozzo A, Figura F, Marchetti M:
The interplay of muscular and exter-
cus and the sartorius. At an individu-
nal forces in h uman ambulation.
real's optirown gait velocity, the plantar
ure flexion thrust (push-off) of the ankle
Summary J Biomech 1976;9:35-43.
5. Meglan D, Todd F: Kinetics of human
nal relieves the hip flexor muscles of their The normal pattern of limb motion
locomotion, in Rose J, Gamble JG
~n- function, conserving energy. The tim- and muscle con trol accomplishes the (eds): Human Walking, ed 2. Balti-
Lct- ing between peak knee flexion and basic objectives of walking, progres- more, MD, Williams &Wilkins, l994,
LXi- thigh advancement is critical fo r sion with weight-bearing stability, pp 73-99.
the clearance of the floor by the toe be- through an optimum interplay of the 6. Winter DA: Energy generation and
sed cause the ankle still Jacks full dorsi- forces generated by positional de- absorption at the ankle and knee dur-
nee flexion (-7°). mand and muscle control. Normal ing fast, natural, and slow cadences.
Lrea function also minimizes the energy Clin Orthop 1983;175:147- 154.
the M idswing (75% to 87% gc) cost of walking, allowing the custom- 7. Eberhardt HD, Inman VT, Bresler B:
:ing With the swing foot ahead of the sup- ary adult walking speed of approxi- The p rincipal elements in huma11 lo-
reporting linlb, the knee begins extend- comotion, in Klopsteg PE, Wilson PD
mately 80 m/min. 15 Because physical
the ing for greater step length. The (eds): Human Limbs and Their Substi-
fitness is reflected in a person's self-
tutes. New York, NY, Hafner Publish-
resulting vertical tibia necessitates selected walking speed, inability to
ight ing, 1968, pp437-471.
continuing ankle dorsiflexion for foot walk at a normal speed is an early
nset 8. Sutherland DH, Cooper L, Daniel D:
clearance of the floor. Near the end of sign of physical impairment. There-
ergy The role of the ankle plantar flexors in
midswing, rapid onset of hamstring fore, knowledge of the normal mo-
e. A normal walking. J Bone Joint Surg Am
muscle action inhibits further ad- tion pattern of walking is a valuable 1980;62:354-363.
)WS.
vancement of the thigh and also tool for the health professional to use 9. Powers CM, Heino JG, Rao SS, Perry J:
nl<le avoids excessive forward swing of the when examini ng a patient. The influence of patellofemoral pain
:>red tibia from inertia. By the end of mid- Focusing on just the basic determi- on lower limb loading during gait.
nius swing, the hip and knee are both nants of walking speed, stride length, Clin Biomech 1999;14:722-728.
,idly flexed 30° and the ankle is dorsiflexed and cadence can be very informative. IO. Powers CM, Reischl S, Rao SS, Perry J:
the to neutral. Stride length depends on both dy- Abstract: Quantification of foot
is no pronation using 3D motion analysis.
I en- nam.ic stability and the mechanics of
Terminal Swing (87% to J Sports Phys Ther 1997;25:67.
1-off progression. Dynamic stability is the
100 % gc) 11. Rao SS, Boyd LA, Mulroy SJ, Bon-
and result of selective tinting and intensity
Knee extension is the final swing mo- trager EL, Gronley JK, Perry J: Seg-
of the controlling muscles, and pro-
tion. This action both completes step ment velocities in normal and trans-
>utes gression is gained from the effective-
length and positions the limb for tibial amputees: Prosthetic design
The ness of the four foot rockers: heel, implications. IEEE Trans Rehabil Eng
stance. Prompt activation of the ankle, forefoot, and MTP joint. Ca-
and 1998;6:219-226.
quadriceps at the beginning of the dence, or the rate of stepping, de-
mus- 12. Brinkmrurn JR, Perry J: Rate and range
phase extends the knee, and continu- pends on the ease of initiating swing
te of of knee motion during ambulation in
ing action of the hamstrings prevents
ment and of accepting the transfer of body healthy and arthritic subjects. Phys
hyperextension. At the end of termi- Ther 1985;65:1055-1060.
ition. weight at the onset of stance. Accom-
11al swing, the Limb is positioned for
plishing these basic determinants of 13. Perry J: Scientific basis of rehabilita-
gc) optimum initial contact. tion. Instr Course Leet l985;34:
walking speed reHes on the mechanics
,leted defined by the eight phases of gait. 385-388.
Kinetics
:i and 14. Lyons K, Perry J, Gronley JK, Barnes L,
Control of the limb during preswing Antonelli D: Timing and relative in-
exion
floor
includes a significant power peak at References tensity of hip extensor and abductor
each joint. At both the anl<le and hip, 1. Inman VT, Ralston HJ, Todd F, Lieber- muscle action during level and stair
flex-
motion-inducing moments include a man JC (eds): Human Walking. Balti- ambulation: An EMG study. Phys Ther
ailing 1983;63: 1597- 1605.
significant arc of generative energy more, MD, Williams and Wilkins,
:s the
(30° ankle plantar flexion and 10° hip 1981. 15. Waters RL, Mulroy SJ: The ene rgy ex-
. The penditure of normal and pathologic
flexion) . In contrast, the dominant 2. Perry J ( ed) : Gait Analysis: Normal and
short gait. Gait Posture 1999;9:207-231.
force pattern that contributes to the Pathological Function. Thorofare, NJ,
sarto-
35° arc of flexion of the knee is an ex- SLACK, 1992.
which

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Amputee Gait
Jacquelin Perry, MD
Introduction
The walking abi lity of a person with a to be preferred in the United King- designs. The functional effects of
lower limb amputation is determined dom for its mobility. 5 However, these advances have been docu-
by both the mechanical quality of the greater weight, limited durability, and mented by gait analysis, which in-
prosthesis 1 and the physiologic qual- arcs of uncontrolled motion in an includes kinematics, dynamic elec-
ity of the residual limb. 2 The primary sensate artificial foot have been per- tromyography (EMG), kinetics, and
determ inants of residual limb quality sistent adverse qualities. The second stride analysis. These measurements
are passive joint mobility and muscle type of foot, developed to circumvent also serve as cEnical standards for in-
strength. Knee flexion contractures the limitations of a mechanical joint, dividual patient management.
greater than 10° were found to be the is a unitary biomechanical solid an-
most significant obstacle to recover- kle-cushion heel (SACH) foot that
ing the ability to walk.3 The disuse was developed by the University of Transtibial Amputee
that accompanies illness or injury is California, Berkeley (UCB) Prosthetic Gait
an insidious cause of muscle weak- Project. In this foot, stability, mobil-
The many prosthetic feet currently
ness. In addition, the most common ity, and durability are effectively inte-
avaiJable for the individual with a
indications for lower limb amputa- grated by the creative combination of
transtibial amputation differ in heel,
tion in the United States-diabetes a solid ankle, cushion heel, dense
ankle, and forefoot mobility because
mellitus and peripheral vascular dis- foam forefoot, and rocker contour.6
of variations in design and material.
ease-impose physiologic limitations The SACH foot became the standard
for function, economy, and durability, Although these variations introduce
on muscle strengthening. A direct
but limitation of progression has re- functional differences, the prosthetic
correlation has been found between
mained a drawback. In the third type feet have an underlying similarity,
muscle weakness and walking speed
in persons with transtibial amputa- of foot, developed to improve pro- that of providing the fundamental
tions.4 Thus, the initial rehabilitation gression without sacrificing stance functions required for walking. For
program to prevent contracture for- stability, the basic design of the bio- each stage of the gait cycle, the funda -
mation and muscle weakening from mechanical foot has been enhanced mental functions are presented first,
disuse is a critical determinant of the by the iutroduction of "dynamic- followed by a review of the unique
future ability of ind ividuals with a response" materials. Two basic de- characteristics of the different pros-
lower limb amputation to walk on a signs have evolved: those with a short thetic designs that have been identi-
prosthesis. spring inside the foot area, such as the fied by comparative studies.
Advances in prosthetic design have Seattle Foot (Model & Instrument The numerous comparisons of the
significantly increased the amputee's Works, luc, Seattle, WA), and those different prosthetic feet have ad-
options. The basic quaEties of the with a longer spring that extends dressed selected designs and func-
prosthetic feet currently available fall from the toes up into the shank, such tions. Here, as in most gait research
into three categories: anatomic, bio- as the Flex-Foot Modular III (Ossur, projects, examples of the four basic
mechanical, and dynamic. The :first Reykjavik, Iceland). Several variations structural classes are discussed.
approach combines anatomic repro- of each are available. Function at the Hence, the data cited will mostly re-
duction with an articulated, single- hip and knee is also being addressed late to the single-axis (Otto Bock,
axis ankle joint. This design continues with newer materials and mechanical Minneapolis, MN), SACH (Kingsley

368 Section UI: The Lower Limb
shoe styles demonstrated. The ran- (rangt

dom pattern of the prosthetic foot additi
Stance Swing data suggested functional similarity 19% c
among the prosthetic feet, in contrast later t
20° to the strong differences between shoe prostl
Plantar styles. Further definition was pre- same
flexion vented by wide variations among in- M1
dividual trials and a loss of data. weigh
The second response to initial heel muse]
contact is the transfer of the energy of contr,
Normal the foot into a heel rocker to rotate weigh
Single-axis foot the foot and tibia forward. 12 All of the arc o-
-20°
Flex-Foot prosthetic designs have a similar load- half t
Dorsiflexion SACH foot ing response. The tibial shank rotates in ten:
Seattle Foot forward at about half of the normal equal
rate. As a result, heel-only support is the d
signrncantly prolonged, averaging mark
0 20 40 60 80 100 21% of the gait cycle (gc) (normal, EMG
o/o Gait Cycle 12% gc) before attaining foot-flat is 40'
floor contact. 8 This slow rate of foot test (
drop extends the heel-only mode of (Figu
Figure 1 Ankle motion of four different prosthetic feet during self-selected speed gait limb support into the period of single majo
in persons w ith a unilateral transtibial amputation, compared with normal.7• 11 stance. 13 Even a delay in contralateral ands
toe-off (16% gc versus 12% gc) does nific,
not resolve the problem.8 Throughout durir
Manufacturing Co, Costa Mesa, CA), The composite prosthetic feet sim- this delay in attaining foot-flat weight prok
foot spring only (Seattle Foot, Model ulate ankle plantar flexion by com- bearing, instability is prolonged as the stanc
& Instrument Works; Seattle Systems, pression of an elastomeric heel cush- dorsiflexion moment remains in ef- tion
Poulsbo, WA), and the shank-foot ion (SACH foot; Seattle lite foot, fect. strict
spring (Flex-Foot) (Flex-Foot, Aliso Seattle Systems) or posterior spring There are notable differences in the tibia
Viejo, CA; Ossur) designs. blade (Flex-Foot). The rate of loading duration of heel-only support among than
response in plantar flexion in these prosthetic foot types. The most pro- flexi<
Weight Acceptance feet is approximately half of nor- longed occurs wiili the SACH foot strin
Ankle/Foot mal8· 11 (Figure 1). With a Flex-Foot, (27% gc)5 and ilie shortest with the grea1
Initial heel contact at the onset of the result is a shorter than normal arc single-axis ankle ( 17% gc). lo between of t
stance imparts significru1t energy to of motion, whereas the slower re- are the Seattle Lite foot (21 % gc) and quac
both the foot and the tibia. The hind- sponse of the SACH and Seattle Lite Flex-Foot (19% gc) . The finding that a T
foot of all prosthetic feet includes heels yields a prolonged arc of mo- highly mobile articulated ankle a11d a indi,
some means of lesseni11g the impact tion. relatively stiff composite prosthetic tion
of abrupt heel loading. These re- The shock-absorbing capability of foot (SACH foot, Seattle Foot, and the.
sponse mechanisms, however, differ prosthetic cushion heels has been Flex-Foot) cause a functionally signif- the l
significantly from normal and also quantified by the reduction of the icant delay in forefoot contact suggests in r~
vary with the design of the prosthesis. peak acceleration at heel strike. Gait that some mechanism other than an- the<
Prostheses with a single-axis ankle measurements were made for five kle mobility is involved. Knee control qua<
joint initiate a short period of plantar subjects walking with six types of may be the related factor. · moc
flexion at the same rate as a normal prosthetic feet. Each series of mea- bot}
ankle. With only a terminal bumper su1·ements was repeated with the sub- Knee imu
for motion control, however, the jects wearing rwo styles of shoes, Motion The peak knee flexion tor ,
magnitude of the free foot drop ex- sports and leather. Among the pros- that follows initial heel contact during flex:i
ceeds normal joint motion by 50%. 7•8 thetic feet, no significant difference prosthetic gait differs significantly !eve
The common response to this hyper- in shock-absorbing capability was from normal function both in magni- orly
mobility is to choose a harder found. The sports shoes registered tude and timing (Figure 2). Advance- cha1
bwnper. As a result, both the arc of notably greater shock absorption than ment of the tibia over the prosilietic (Fig
plantar flexion and the duration of did the leather shoes in 80% of the heel occurs at a rate approximately lar t
recovery to neutral are exaggerat- comparisons. Only with the two stiff- half of normal. The resulting arc of of fl
ed.s,9,10 est feet was no difference between knee flexion is far less than normal ittal

Chapter 30: Amp utee Gait 369
an- (range, 60 to 100 versus 180) .11,14,1s In

oot addition, peak flexion is delayed until Stance Swing
rity 19% or 20% gc, which is significantly 60°-
rast later than normal (12% gc). All of the Normal
Flexion
hoe prosilietic foot designs present the Single-axis foot
>re- same pattern of knee flexion. Flex-Foot
40°-
in- Muscle Control Throughout SACH foot
weight acceptance, ilie quadriceps Seattle Foot
1eel muscle group contracts vigorously to
y of control the rate of knee flexion for 20°-
tate weight-bearing stability. Whereas the
the arc of knee flexion is approximately
>ad- half that of the normal range, ll, tG the
O~·flJ':::::~~~~~-==~ ~~ ,,,c.,.;_~-1--~~~~~~--,,-~
a tes intensity of tlle quadriceps EMG is
Extension
ma! equal to or greater than normal, and
-10°
rt is the duration of quadriceps activity is
ging markedly prolonged. Peak quadriceps 0 20 40 60 80 100
mal, EMG intensity during prosthetic gait
-flat is 40% of maximum manual muscle % Gait Cycle
15
foot test (MMT) versus tlle normal 29%
.e of (Figure 3). In addition, both of the Figure 2 Kn ee motion of four different prosthetic feet during free-speed gait in per-
ngle major hamstrings (biceps femoris 14 sons w it h a unilateral transtibial amputation, compared with normal.7 •11
teral and semimembranosus 15) register sig-
does nificantly higher than normal EMG
hout du ring weight acceptance and have
!ight prolonged activity through most of Stance Swing
s the stance (Figure 4) . This pattern of ac-
1 ef- tion implies a deliberate effort to re-
Normal
strict the knee flexion of the residual ............... Flex-Foot
n the tibia to an arc significantly shorter - - - SACH foot
nong than normal. Also, the increased knee ·------··- Seattle Foot
pro- flexion that accompanies tlle ha m-
foot string muscle response to provide
1 the greater support to the flexed posture
ween of the hip necessitates additional
) and quadriceps control.
,hat a The reason for reduced flexion in
mda individuals with a transtibial amputa-
thetic tion is not clear, but it can be related to -10
, and the anatomy of tlle extensor system of
ignif- the knee. The normal knee flexes 20° 0 20 40 60 80 100
~gests in response to rapid weight transfer at
nan- the onset of stance. An analysis of the
0
/o Gait Cycle
>ntrol quadriceps demand witl1 a mechanical
model showed that knee flexion of Figure 3 EMG activity of the vastus lateralis, representi ng quadriceps muscle action,
both 5° and 15° required 20% of max- during free-speed gait in persons w it h t ranstibial amputations using t hree different
imum strength. 17 The equalizing fac- prosthetic feet. 15
lexion tor during the first 10° to 15° of knee
luring flexion was the increase in quadriceps yond iliis position, further flexion is that weight bearing on a knee flexed
cantly leverage as the femur rocked posteri- gained by the combined roll and slide 30° required a significantly greater
rngni- orly on the tibia and the simultaneous of the femur on the posterior surface quadriceps torque (up to 50%) . In the
19 transtibial amputee, a greater quadri-
rance- change in articular con tact areas18• of the tibia (Figure 5, B). Aliliough this
,the tic (Figure 5, A). The lengtl1 of the patel- decreases the leverage of the patella, ceps force would increase distal tibial
11ately lar tendon lever arm is maximal at 15° the quadriceps force is significantly in- pressure against ilie socket, and this
arc of of flexion because of the enlarged sag- creased by greater sarcomere length. may be what the transtibial amputee is
,o rmaJ ittal contom of the distal femur. 17 Be- The mechanical model also showed avoiding.

370 Section III: Th e Lower Limb
80-
80 Stance Swing
Normal
60 ............... Flex-Foot
- - - SACH foot
•••••••••• Seattle Foot ........ .. Amputee
Normal
A
20 40 60 80 100 0 25 50 75 100 Figu
% Gait Cycle % Gait Cycle cont
A B ere a
for111
Figure 4 Hamstrings muscle action during free-speed gait in persons with transtibial amputations using three different prosthetic
feet.15 A, Biceps femoris, long head. B, Semimembranosus. tact
app
The
sam
80 but
Stance Swing pre:
tan,
the
60 Normal con
.............. . Flex-Foot th~
- - - - SACH foot red
·········- Seattle Foot ing
the
cep
the.
gra
Figure 5 Joint surface contact pattern of 20
the femur and tibia during knee f lex-
HiJ
ion. 18 A, Flexion from 0° to 15°: equal
posterior displacement on both joint sur- The
faces (rocker effect). B, Flexion from 15° O-t-....:=.;:'---t~.-..._.,.......,.___...,..____-+..... . - . i ~ gai1
to 140°: The femora l surface continually am
changes, but tibial contact remains rela-
0 20 40 60 80 100
cep
tively constant (roll and glide). % Gait Cycle
fie>
sig1
the
Figure 6 EMG activity of the lower portion of the gluteus maximus muscle (a hip exten·
Studies of the gait mechanics of a sor) while walking at a self-selected speed. The intensity is greater than normal with all ext
person with a Syme ankle disarticula- three types of prosthetic feet. Prolonged activity ceases shortly after t he end of heel- irn1
tion tend to confirm that tibial stabil- only support (average, 22% gc). (Adapted with permission from Kapandji IA (ed): Phys- vig
iology of the Joints. London, England, E&S Livingstone, 1970, p 89.) arn
ity within the prosthesis is important
(J Perry, MD, unpublished data, de1
1989). Both transtibial amputees and ma
those who have undergone the Syme tact provided by the length of the lation showed a peak knee flexion of of
procedure use similar types of pros- tibia and the broad distal surface of 14° during limb loading, a position
theses, but the Syme procedure pre- the Syme procedure would be ex- very close to normal. wa
serves sufficient tibial length for pected to notably enha11ce stability of th~
One difficulty in comparing quad-
weight bearing on the end of the re- the prosthesis. Gait analysis of an in- loa
riceps strength in a limb with a trans-
sidual limb. Also, the increased con- dividual with a Syme ankle disarticu- tibial amputation with that of an io·
gn

Chapter 30: Amputee Gait 371
~----
=
0
A - -- B c -= D
figure 7 Floor contact pattern in a person with a transtibial amputation using a SACH foot. A, End of weight acceptance: Forefoot
contact still lacking. B, Early single-limb support: The premature heel rise is obvious. C, Terminal stance: Step length is gained by in·
creased heel rise, which, combined with an extended knee, elevates the body mass. D, Preswing: Rapid drop of body weight onto the
forward limb initiates a visibly vigorous quadriceps response.
hetic
tact limb is the effect of the resistance sponding postw-e would be a slight mal with the Flex-Foot a11d 33% with
applied against the proximal tibia. forward lean to lessen the extensor the SACH foot.22
Theoretically, muscle moment is the moment at the knee and, thereby, also The arcs of dorsiflexion identified
same at both ends of the distal bone, reduce the need for quadriceps power during walking are compatible with
but the internal mobility of the knee to stabilize the knee. instrumented stiffness tests. Nine in-
presents a unique situation. Resis- dividual designs fall i11to two very dif-
tance against the upper tibia opposes Single-Limb Support ferent categories.23 The stiffer ones,
the anterior drawer that normally ac- Ankle with a deformation value of 0.076 to
Having attained weight-bearing sta-
]
companies quadriceps activity when 0.061 N/m , are designs using intrinsic
the knee is flexed less than 30°. This bility, the limb and body mass advance foot flexibility (SACH and Seattle Lite
reduces the patellar lever, with result- over the single supporting foot. AU feet), whereas the flexible shaft design
ing weakness of knee extension. 20 In prosthetic feet accomplish some tibial of the less stiff prosthetic feet (Flex-
the patient with borderline quadri- progression, although the mechanics
Foot; and College Park Foot, College
ceps strength, a snug fit of the pros- differ. The SACH foot, limited by a
Park Industries, Fraser, MI) presented
thesis against the tibia could be an ag- solid keel, allows little foot-flat stabil-
half as much resistance to deforma-
gravating factor. ity. Instead, the prolonged heel-only
tion (0.038 to 0.028 N/m).
contact during the loading response is
Hip almost immediately exchanged for
The motion pattern of the hip in the premature heel rise as the shank ad- Knee
' gait of individuals with a transtibial vances beyond vertical 5 (Figure 7). Motion From its limited flexion at
1 amputation is similar to normal ex- The final heel rise is hvice the normal
100 the end of the loading response, the
cept for an average 10° increase in elevation. In contrast, the flexible knee slowly extends. Maximum exten-
flexion. 11• 14' 21 Dynamic EMG shows a shank of the Flex-Foot allows a pro-
sion to neutral is attained near the
significant increase above normal in longed period of foot-flat stability as
end of terminal stance (45% gc), then
the intensity and durntion of the hip the shank advances (Figure 8). The
exten· the knee begins to flex. Consistent
vith all extensor function of the gluteus max- Flex-Foot also provides significantly
with its greater arc of ankle dorsiflex-
f heel· imus (Figure 6) . The accompanying greater ankle dorsiflexion (20°) in ter-
ion, the Flex-Foot tends to initiate
I: Phys· vigorous action of the biceps femoris minal stance than the other prosthetic
foot designs (13°) .5' ll ,J 6 The cited arcs knee flexion slightly sooner.
and semimembranosus, which, inci-
imply more mobility than that of the
Muscle Control Continuing
dentally, increases quadriceps de-
normal ankle (10° dorsiflexion), yet quadriceps activity at a diminishing
mand, confirms that the primary role
11 15
the prosthetic stride length is shorter intensity provides active knee exten-
jon of of these muscles is hip control. •
Analysis of hip kinetics dUTing than normal. This inconsistency sion. Generally, this muscle relaxes as
)Sition
walking demonstrates an increase in stresses the difficulty of defining the midstance ends (30% gc) , but it may
the internal extension moment in ankle ax.is of a prosthesis. \Nhen total continue until 40% gc. Prolonged
quad-
loading, 14 which correlates with the tibial advancement is assessed, how- quadriceps activity is particularly
trans-
greater EMG reported. The corre- ever, progression is only 67% of nor- likely with a SACH foot.
an in-

372 Section Ill: The Lower Limb
c
Cl)
E Pl
O fl
2
Dors
A B c D
Figure 8 Floor contact pattern in a person with a t ranstibial amputation using a Flex-Foot. A, End of weight acceptance: The onset of A
forefoot contact initiates stable f lat-foot support. B, Early single-limb support: Prosthetic "ankle" dorsiflexion continues foot-f lat sup-
port while t he tibia advances. C, Terminal stance: The combination of continuing foot -flat support and excessive prosthetic "ankle"
FigurE
dorsiflexion allows a longer step without elevation of the body. D, Preswing: Unloading body weight from t he t railing limb allows the
prosthetic ankle to rebound to neutral. later.a
Czern
Med I
Hip versely, prostheses dependent on in- dorsiflexion. The push-off rate for the
Motion As the body rolls forward trafoot flexibility fo r tibial progres- single-axis and Seattle Lite feet aver- of kr
over the supporting foot, the limb sion have a material-imposed delay. ages 61 % of normal, and these feet sons
falls into a trailing position as the hip T hese interpretations have yet to be have a smaller arc of motion. ing 1
joint extends. The hip of the pros- statistically supported by the pub- Anot
lished data because of the small m11n- Opposite Limb Demand is a I
thetic limb uses less hyperextension
(10°) than does the opposite limb ber of subjects tested in the compari- The second effect of weight transfer is SUS 6
(20°), 2 1 which is consistent with the son studies. Statistical power analysis the load imposed on the opposite
indicates that 25 subjects would be limb. 11 •24 •27, 28 Most prosthetic foot Kin
reduced arc of tibial progression at
the foot. needed to doctunent a difference in designs significantly increase the Mon
Muscle Control The duration of stride length, 11 yet tl1e detailed com- loading force transferred to the oppo- limb
hip extensor muscle action differs parisons of the gait of different pros- site limb, averaging 130% of body tion:
with prosthetic foot mobility. Only thetic designs have included only 5 or weight compared with the normal fro ff
10 subjects. s,11.14- 16,21,22,24. 26 111 % . In contrast, the opposite limb's duri:
the gluteus maximus consistently
vertical force in persons using a Flex- in flu
ceases activity shortly after the heel-
only support ends (about 21 % gc)
Preswing Limb Foot ( llOo/o of body weight) does not with
Advancement exceed a normal response. 16•29 •30 The tion
(Figure 6). The biceps femoris EMG
Ankle functional difference between these sorp
has a similar early drop in intensity,
prosthetic feet resides in the ability to T
but lower levels of muscle action per- The onset of double-limb support
move forward over the prosthetic pros
sist until the end of stance (Figure 4, signifies the beginning of body weight tern
limb, which is identified by t11e arc of
A). The consistency of the gluteus transfer from the prosthetic foot to join
terminal stance dorsiflexion. The in-
maximus EMG compared with the the intact ]jmb. Each limb is signifi- creased rate of weight transfer is also one
variability of the biceps femoris reac- cantly affected. evidenced by the rapid onset and
tion implies that the knee is more di- Rapid unloading of the trailing magnitude of the vastus lateralis We
rectly i11fluenced by prosthetic foot limb releases the energy stored in the EMG. Although the magnitude of Att
mechanics than is the hip. The differ- dorsiflexed prosthetic foot. The reac- heel rise has not been measured, the pact
ences in the response of the biceps tion, a fast arc of "ankle" plantar flex.- very premature heel rise of the SACH inte
femoris reflect the mode of tibial pro- ion for "push-off;' is merely a reversal foot is a well-recognized consequence reac
gression provided by the various of the prior dorsiflexion motion. of its restricted tibial advancement. by
prosthetic designs. T he premature None of the prosthetic feet moves be- The substitution of heel rise for lim- oth(
heel rise of the SACH foot over a rigid yond the zero position 11 (Figure 1) . ited dorsiflexion would elevate the con
but favorably contoured keel initiates T he Flex-Foot, by attaining the body as the foot rolls forward on the the
an early forefoot rocker, which facili- greatest dorsiflexion in terminal forefoot rocker, thereby creating a var1
tates advancement of the tibia, and stance (23° versus 12°), has the fastest greater drop onto the opposite ]jm b. thet
shank flexibility provides a similar rate of plantar flexion (71 % of nor- These limb-loading mechanics have not
advantage to the Flex-Foot. Con- mal),8 but the motion ends at 5° of been related to an increased incidence kle

Ch apter 30: Amputee Gait 373
500
Normal Normal
,.............. Flex-Foot 375 ....... ........ Flex-Foot
- - - SACH foot SACH foot
•••••••••• Seattle Foot •••••••••• Seattle Foot
Stance [250
c
(l) 20
i 125
E Plantar &_
~ flexion 0 -
-125
Oorsiflexion
- 10
-250+--- - - ~ - - -~ - - - ~- -~
0 20 40 60 80 100 0 25 50 75 100
% Gait Cycle B % Stance
it of A
SUp·
kle" Figure 9 Ankle kinetics of three different prosthetic feet generated during the stance phase of free-speed gait in persons w ith a uni-
,the lateral transtibial amputation, compared with normal. A, Ankle moment. B. Ankle power. (Adapted with permission from Gitter A,
Czerniecki JM, DeGroot OM: Biomechanical analysis of the influence of prosthetic feet on below-knee amputee walking. Am J Phys
Med Rehabil 1991;70:142-148.)
:the
Lver- of knee osteoarthritis in elderly per- Loading the knee generates a The hip shows a reverse pattern as
feet sons with a long experience of walk- markedly reduced extensor moment. both the magnitude of the moment
ing with a transtibial amputation.3 1 The normal peak moment is 0. 70 and the power increase (Figure 11, A) .
Another demand on the opposite leg N·m; for the transtibiaJ ampu tee, the The timing of their peaks differs,
is a longer stance time of 66% gc ver- peak moment is less than I 0% of this however. T he peak extensor moment
fer is sus 63% gc for the prosthetic limb.. vaJue15 (Figure 10). This reduction in is delayed, occurring at 10% gc versus
osite moment is consistent with the limited the normal 3% gc. Hip power in-
foot Kinetics arc of flexion that occurs during load- creases immediately following heel
the Moments define the balance of ·the ing response and has been interpreted strike (Figure 11, B). Peak power aver-
ppo- limb's antagonistic forces (muscle ac- as an energy-saving situation. ages 16 W for prosthetic feet com-
body tion) in the designated plane derived The less flexible prosthetic feet pared with the normal 6 W. Hence,
,rmal from the postures and motions used (the SACH and Seattle feet) experi- the kinetic data indicate a significant
unb's during walking. Power identifies the ence a slight reversal of the knee mo- increase in extensor muscle activity at
Flex- influence of speed on the moments, ment toward flexion, and t he usual the hip and a decrease in extensor
s not with the outcome defined as accelera- power peaks are absent. Although the muscle activity at the knee.
I
The tion (generative) or deceleration (ab-
Flex-Foot has a slight extensor mo-
these sorptive).32 Terminal Stance
ment, it also lacks any significant
ity to The dominant intervals ·of the
peaks of power at the knee. 14 Throughout the period of single-limb
thetic prosthetic gait are weight acceptance,
The realignment of the knee mo- support, a progressively greater plan-
H"C of terminal stance, and preswing. Each
ments of the SACH and Seattle pros- tar flexor moment develops as the
1e in· joint has a dominant force pattern in
thetic feet (and, to a lesser extent, the body weight vector advances over and
s also one of these intervals.
Flex-Foot moments) toward flexion beyond the foot. The responses of
and
Weight Acceptance implies increased hamstring flexor prosthetic feet differ significantly
:eralis
muscle action (Figure 10, A). The cor- (Figure 9, A ). By the end of terminal
ie of At the ankle, the response to the im-
responding sharp increase in hip ex- stance, the peak plantar flexor mo-
d, the pact of initial heel contact is a small
tensor power (Figure 11, A ) suggests a ment of the Flex-Foot is twice as great
;ACH internal dorsiflexion moment that
forward trank lean as a means of reas that of the SACH and Seattle feet,
uence reaches its peak magnitude of 4 N·m
ment. by 10% gc and then persists for an- ducing the knee moment. The logical which is closely related to the amount
r lim- other 8% to 14% of gc before forefoot stimuli for this postural adaptation of dorsiflexion permitted by each foot
:e the contact occurs. 13' 14 The duration of are the challenge to balance over the design. 11
m the the dorsiflexion moment does not lim ited area of support provided by During this action, power is ab-
ing a vary significantly among the pros- the heel and a need to reduce the knee sorbed at an increasing rate (Figure 9,
1imb. thetic foot designs (Figure 9, A). No extensor demand. Power generation is B). Power storage with the SACH foot
, have notable power is generated at the an - minor during weight acceptance (Fig- is minima.I, but it is notably increased
idence kle daring weight acceptance. ure 10, B). in both the Flex-Foot and the Seattle

burst
with
150
prep a
Normal 500
............... Flex-Foot Normal Ene1
100 - - - SACH foot ............... Flex-Foot
375 The .1
·········- Seattle Foot - - - SACH foot
E •••••••••• Seattle Foot mom
~ 50 ~250 prete,
.._
c
Q.)
Extension .... Extension provi
Q.> 125 respo
E 3
0 0
~ 0 a. netic:
0 •••••• ....,':-: • ••• : .......-,,,&.. ••••• .... . . . . . .. ........ ..
signs
Flexion
SAO
· 125
-50 Flexion thee
meas
-250
0 25 0 25
signi1
50 75 100 50 75 100
% Stance all pl
% Stance
A B uals
comr
Thos
Figure 10 Knee kinetics of three different prosthetic feet generated during the stance phase of free-speed gait in persons with a uni-
lateral transtibia l amputation, compared w ith normal. A, Knee moment. B, Knee power. (Adapted with permission from Gitter A. by d)
Czerniecki JM, DeGroot OM: Biomechanicaf analysis of the influence of prosthetic feet on below-knee amputee walking. Am J Phys oxyg,
Med Rehabil 1991;70:142-148.) limit
com1
trast,
500 cally,
tion)
375 ( 47o/,
Normal to v
............... Flex-Foot
Normal 250 (83 I
- - - SACH foot
............... Flex-Foot [ Extension ····· ···-- Seattle Foot ergy
SACH foot ... 125 cost!
20 Extension •••••••••• Seattle Foot
Q)
s:0 Non
c a. 0
Q)
E
sho"'
0 0 ener.
~ ·125 Flexion T
10
-250
closE
0 20 40 60 80 100 0 25 50 75 100 grea·
% Gait Cycle % Stance duri
A B cont
rnuc
Figure 11 Hip kinetics of three prosthetic feet generated during the stance phase of free-speed gait in persons with a unilateral trans· to b
tibial amputation, compared w ith normal. A, Hip moment. 11 B, Hip power. (Adapted with permission from Gitter A, Czerniecki JM, De· imp,
Groot OM: Biomechanica/ analysis of the influence of prosthetic feet on below-knee amputee walking. Am J Phys Med Rehabi l 7997;
70:142-148.) SUpf
two
arc
Foot. These differences are reflected absorption capability, the SACH foot ble absorptive power (Figure 10). This and
in their preswing response. generates minimal power. Conversely, is an interval of rapid, vital, passive betv
the more flexible Flex-Foot creates a flexion in response to the push-off ac· a st
Preswing power spike five times as great, and tion of the ankle, which seldom needs thet
The relatively fast rate of unloading the concentric power of tJ1e Seattle restraint. The calculated power re· app.
the limb by weight trnnsfer trans- Foot lies midway between the two, al- fleets the interaction of high-speed inar
forms the plantar flexor force into a though aU are significantly less than motion and low force. com
spike of generative power, commonly normal. The hip has a relatively normal foot
identified as ilie push-off force of the The knee has a moderate extensor power pattern during the later phase in [
foot (Figure 9, B). With little energy moment dming preswing, with nota- of stance. Io preswing there is a small

burst of generative power consistent becomes vertical. Th is imposes an in- whereas the instability introduced by
with the hip flexor action assisting in creased demand on the quadriceps. the unrestricted mobility of the
preparation for swi ng (Figure 11, B). The higher intensity of the hip ex- single-axis foot (twice the rate of a
tensor EMG, unlike the merely pro- normal ankle) further augments the
Energy longed quadriceps EMG, implies vol- need for muscular effort. A design
The reductions in the knee extensor untary protection of the transected that represents a functional compro-
moment and power peaks are inter- tibia. Increased hip extensor muscle mise between these two extremes is
preted as energy-saving mechanics action is a well-recognized protective needed.
provided by the newer, dynamic- gait for a weak quadriceps. A slight Muscular exertion of the sound
response prosthetic feet. Yet, the ki- forward trunk lean reduces the exter- limb during weight acceptance results
netics of the various prosthetic de- nal flexor moment at the knee, from the excessive ground-reaction
signs differ little from that of the thereby decreasing the pull of the force created by prosthetic foot de-
SACH foot. Direct determinations of quadriceps. In the amputee with a signs, which maximize tibial advance-
the energy costs of prosthetic gait by transected tibia, anterior displacement by heel rise as a substitute for
measurement of oxygen use show a ment of the distal tibia would be sim- inadequate ankle dorsiflexion.
1 significant increase over normal with ilarly reduced.
JO
all prosthetic foot designs. 33 Individ- To date, efforts to reduce tl1e en-
uals with transtibial amputations ac- ergy cost of prosthetic gait have fo- Transfemoral
commodate this increase in two ways. cused on improving push-off. Yet, the Amputee Gait
Those who are limited physiologically major muscle group normally respon-
Iuni- Amputations through the femur not
er A,
by dysvascular disease keep the rate of sible for this action, the gastrocne-
oxygen use within 10% of normal by mius-soleus complex, is lost with the only deprive patients of the limb seg-
Phys
limiting walking speed (60 m/min, transtibial amputation, which leaves ments that contain and control the
compared with 86 m/min). 2 In con- the hip flexors as the source of swing- knee and foot, but also weaken the
trast, physically fit amputees (typi- phase limb advancement. Although musculature controlling the hip. Sur-
cally, those with a traumatic amputa- the hip flexor muscles are activated gical division of the tendons and
tion) accept a higher energy t·ate with each step, overuse symptoms are muscles allows the residual muscle fi-
(47% greater than normal) in order rarely noted, as the flexion arc is only bers to retract because the viscoelastic
to walk at a nearly normal speed 30°. The peak intensity of normal sarcomeres have lost their tether, 35
(83 m/min). For both groups, the en- function is 20%, a state that allows and undue shortening of the sarco-
ergy expenditure per meter traveled is full muscle O>..')'genation.34 The gait meres entails the loss of muscle
force.36
--
costly ( 45% greater than normal) .33 mechanics identified in this chapter
None of the prosthetic foot designs strongly indicate tl1at efforts to reduce An additional threat to optimal
...... shows any significant difference in the the energy cost of walking for ampu- function is the hip's natural resting
energy requirement of walking. tees shoul d be redirected to the func- posture. Experimental distension of
These higher energy values relate tions involved in weight accep~ance. the hip by sterile plasma injection has
closely to the EMG evidence of identified that intra-articular pressure
i greater hip and knee muscle activity Conclusions (indicative of capsular tension) is
100
during weight acceptance and the For persons with transtibial amputa- lowest when the hip is in 30° of flex-
continuation of this activity through tions, tl1e biomechanical demands of ion, 15° of external rotation, and ab-
much of stance. The stimulus appears weight acceptance necessitate height- duction . Hence, this is the posture the
trans- to be the prolonged tibial instability ened muscular control by both the injured hip spontaneously assumes.
1,1, De- Consequently, early rehabilitation
imposed by heel-only support. This prosthetic and sound limbs and are
1991;
support pattern, in turn, is related to thus likely responsible for much of must include both vigorous contrac-
two significant situations, the short the elevated energy cost of transtibia1 ture prevention and extensor muscle
arc of loading-response knee flexion amputee gait. strengthening.
. This and the fixed orthogonal relationship Muscular exertion on the pros-
assive between forefoot and shank. To attain thetic side during weight acceptance Motion
>ff ac· a stable foot-flat posture, the pros- results from insufficient knee flexion Ankle/Foot
needs thetic shank must be vertical, as the and persistent ankle dorsiflexion, All prosthetic foot designs initiate
:r re· apparent "plantar flexion" is merely a which perpetuate the postural insta- stance with the heel. Active inhibition
speed marker of displacement from heel bility created by the heel rocker mo- of knee flexion by the transfemoral
compression, not a drop of the fore- ment. The various cushion heel de- amputee has two effects: ( 1) heel-only
ormal foot on the shank. With the knee held signs allow the forefoot to sink support is continued until the lin1b is
phase in relative extension, the whole body toward the floor but do not alter its erect, and (2) the locked knee extends
small must advance with the tibia until it alignment relative to the tibia, the influence of the heel rocker to the

of knee flexion . The 5° reduction

Knee Flexion/Extension (compared with the knee flexion al-
70 lowed by a fow--bar mechanical knee
joint) shortens the duration of swing.
60 Despite this aid, the swing phase of a
50 prosthetic knee is still slower than
-
~
Q)
40
that of the sound limb. 38
Microprocessor-controlled hydrau-
lic knees, such as the Intell igent Knee
"6> 30
c (Chas. A. Blatchford & Sons, Ltd, Bas-
<(
20 ingstoke, Hampshire, England) and
t he C-Leg (Otto Bock HealthCare,
10
Inc, Minneapolis, MN) have recently
0 become available. They use on-board
~
Extension computers to monitor limb motion
-10 a11d to readjust resistance to flexion
25 50 5 10
and extension up to 50 times per sec-
% Gait Cycle
ond.39 Preliminary gait analysis has
demonstrated a sign ificant reduction
Figure 12 The motion pattern of the prosthetic knee during stance phase in persons in energy cost.
with a unilateral transfemoral amputation. The data are mean (bold line) and standard FigL
deviation (thin lines) for 25 subjects. Normative data (shaded region) are provided for
Published reports, which have
(Da
comparison. The width changes shape as it represents the standard deviation for the re- been limited primarily to subjective
spective groups. (Adapted with p ermission from Boonstra AM, Schrama JM, Eisma WH, disciplines, suggest improved walking
Hof AL, Fidler V: Gait analysis of transfemoral amputee patients using prostheses with ease. In one study, 12 amputees using the
two different knee joints. Arch Phys Med Rehabil 1996;77:515-520.) the Intelligent Knee noted the ability Coi
to var y their speed and a reduction in mo
fem ur, thereby accelerating the pro- the end of terminal swing approaches, energy demand, which enabled them 73~
gression of the whole limb over the the kn ee is fully extended (0°). Load- to walk farther. 40 One user reported me
supporting heel. ing of the limb may initiate 5° of flex- that the C-Leg eliminated the need to gro
ion, but genera1ly the joint is mai n- pull the hip extensors back to stabilize Du
The magnitude of knee flexion on
tained at 0° throughout stance. Then , the knee. 41 Measured energy cost for rev
the prosthetic limb is indicative of the
37 one user demonstrated a 10% reducing
quality of swing-phase knee control. just before toe-off, knee flexion be-
tion in demand when walking with to
For example, during slow gait, a hy- gins in order to meet the floor clear-
the C-leg compared with a customary tirr
draulic dampening system is prone to ance requirements of swing. Knee
prosthesis. 42 ter:
retard flexion excessively, as is indi- flexion is rapid, with approximately
The control mechanisms that en- ten
cated by a reduction in the maximum 65° of flexion attained by midswing.
able the C-Leg to reduce the energy
knee flexion. Conversely, during fast Once peak flexion is reached, the knee
cost of walking have not been re-
walking, a constant-friction mechani- rapidly extends in preparation for the im
ported, but by comparing the hip and
cal knee allows excessive knee flexion next period of stance. pu
kn ee motion patterns of one amputee
because of inadequate restraint. Recently, prosthetic knees that per- ter
fitted with a C-Leg to the typical gait
Prematme rnidstance plantar flex- mit 5° to 12° of stable knee flexion ma
of persons walking with a customary
ion by the sound limb assists toe during loading response have become pa1
transfemoraJ prosthesis and the mean
clearance of the prosthetic limb by available. Gait studies have shown m~
normal gait pattern, the genera] ap-
lifting the body. Vaulting is the clini- that although such "stance fl.exion" proach can be deduced. The most im-
vie
cal term for this event. Excessive plan- occurs, the magnitude of knee flexion its
pressive contribution of the C-Leg
tar flexion during preswing denotes is less than normal and occurs later i.n microprocessor knee joint was repli- 20'
an extra push-off effort to facilitate the gait cycle. Peak knee flexion in cation of the normal pattern of of
progression of the prosthetic limb midswing occurs too late to assist in swing-phase knee flexion. Although ral
during weight acceptance. toe clearance. In fact, the normal limb the onset of knee flexion was slightly lo,
has a critical arc of knee flexion of 40° delayed , the abrupt initiation of a fast C-
Knee in preswing to supplement the final a rc in mid preswing (55% gc) pro· pa
Most prosthetic knees obligate per- 20° attained in initial swin g as hip vided the range needed for ground ab
sons with transfemoral amputation to flexion advances the limb. clearance. At normal toe-off (62% ite
avoid flexion during stan ce so that the A pneumatic swing-control knee gc), the knee was flexed 35°. Toe lift, ra1
knee does not collapse (Figure 12). As joint reduces the rate and magnitude aided by the slightly dorsiflexed pros- Sp,
American. Academy of Orthopaedic Surgeons

ion thetic knee. Prolongation of hip ex-

al- Hip Flexion/ Extension tension into the middle of preswing
nee 70 provided the necessary compensation
ing. to stabilize the limb until body weight
60
:>fa was transferred to the other limb.
han 50 This allowed the knee to be readied to
:au-
:nee
-
0
(1)
40
respond to the subsequen t rapid initi-
ation of flexion required for swing.
0) 30
Thus, the basic phasing of stance
Bas- c stability and swing progression was
<{
and 20 determined by active hip control. The
:a.re, C-Leg, by superimposing timely mag-
10
:ntly nitudes of force within the knee, re-
:>ard 0 duces the energy demand of walking
,tion and provides a more normal gait pat-
xion -10 tern fo r persons walking with a trans-
sec- 50 5 1 0 femoral prosthesis.
has % Gait Cycle
:tion Hip
The pattern of hip motion recorded
Figure 13 The motion pattern of the hip in persons with transfemoral amputations.
have for persons with transfemoral ampu-
(Da ta [unpublished] courtesy of Ayyapa.)
ctive tations represents displacement of the
Lking prosthesis as the femur is obscured by
1sing thetic foo t (5°) , would be adequate. T he motion pattern of initiating the socket. A significant difference
bility Continuation of this fast r ate of knee thigh retraction immediately after from normal gait is the abruptness of
:>n in motion also attained 58° of flexion by initial contact, rather t11an preserving the postural change (Figure 13). At
them 73% gc. Both magnitude and timing the normal loading response flexion, initial contact, the hip is flexed ap-
orted met the tigh t requirements for supported this interpretation. As the proximately 37°.43 As the limb is
ed to ground clearance by a swinging limb. hip actively extended from 35° of loaded, the hip immediately begins to
bilize During midswing, the knee's motion flexion at initial contact, the femur extend, reaching 5° of hyperextension
st for reversed into extension, and contin u- would simultaneously become more by the end of single stance (50% gc).
educ- ing movement at a rapid rate (similar vertical. This, in turn, would move Then, during the next 25% of the gait
with to that of the flexio n arc) provided the body weight vector closer to the cycle, the hip flexes to 35° at a rate of
,mary timely extension for stance. By m id knee, and the combined effects would motion twice that used for hip exten-
terminal swing, the knee had ex- reduce the added effort required to sion. This is followed by a slow ad-
1t en- stabilize the knee. The duration of vancement to the final flexed posi-
tended to 5° of flexion.
nergy loading response, however, also could tion.
The motion pattern during stance
n re- be prolonged (20% gc versus 12% gc), Significant motion of the residual
implied either less concern by the am-
p and as decreased knee flexion required the limb within the prosthetic socket bas
putee for replicating the no rmal pat-
tputee whole limb to roll fo rward until the been identified by ultrasound.44 In the
tern of knee motion or a more de-
al gait vertical shank permitted foot-flat sagittal p lane, initial contact is fol-
manding situation. The gross motion
)mary support. On the other hand, the lowed by a rapid 7° arc of extension.
pattern appeared to be similar to nor-
mean C-Leg can provide the knee flexion This position is m aintained until the
al ap- mal, but the initial flexion wave pro- end of terminal stance (Figure 14, A).
needed for reciprocal limb support
,st im- vided by the C-Leg was smaller a nd during stair descent. The difference Then, in preswing, the residual limb
C-Leg its peak delayed (10° of flexion at may be the result of the control re- rapidly reverses to a peak of 7° of flex-
repli- 20% gc) compared with no rmal (20° quired to allow an arc of flexion while ion by toe-off. T his flexed position is
rn of of flexion at 12% gc). The transfemo- also stabilizing the knee against a maintained until neutral alignment is
hough ral prosthesis customarily has no rapid increase in body load compared regained in terminal swing. In the
;lightly loading response flexion; hence, the with allowing a previously stabilized coronal (frontal) plane, a similar pat-
fa fast C-Leg represented a compromise: a limb to yield into an arc of flexion . tern of rapid abd uction and subse-
) pro- partial, rather than full, shock- T here were indications that the quent release occurs, but swing in-
;round absorbing wave. T his implied a lim- end of stance required hip control ad- volves only a minor interval of
(62% ited ability to reproduce the normal aptation. The prolonged dorsiflexion adduction (Figure 14, B). For most in-
be lift, rate and magnitude of the knee's re- of the prosthetic foot for step length dividuals with transfemoral amputa-
:i pros- sponse to limb loading. would inadvertently flex the pros- tions, the range of hip motion by the

10 10
8 8
Flexion Abduction
6
(deg) (deg) 6
4
2 4
0 2
-2
0
-4
Extension Adduction -2
(deg) -6 (deg)
-8 -4
HS HS B HS HS
A
Figure 14 Motion of the residual femur within the socket recorded by ultrasound during level walking by a person with a transfem-
oral amputation. A, Flexion/extension. B, Abduction/adduction. HS = heel strike. (Adapted with permission from Convery P, Murray KO:
Ultrasound study of the motion of the residual femur within a trans-femoral socket during gait. Prosthet Orthot Int 2000;24:226-232.) Figl
A, C
ing
per
Th<
int<
--S.E E
the
to
.2.
0 0 . mu
ro ro
~
{)
..... •t
of I
~ ~ (er,
glu
-10 -10 clei
inti
-15 0 15 -15 0 15
anc
Lateral (cm) Lateral (cm) cep
A B tra'
sue
Figure 15 Transverse planar motion of the pelvis generated during one gait cycle as a person with a transfemoral amputation walks har
on a level surface. A, Good walker. B, Poor walker. (Adapted with permission from Tazawa E: Analysis of torso movement of trans- ten
femoral amputees during level walking. Prosthet Orthot Int 1997;21:129-140.) am
tor
prosthetic limb is about 80% of that extension (lordosis) occurs. Pelvic d isplay asymmetric displacement pat- de1
used by the opposite limb. Femoral mobility is greater in these amputees terns, which may cover twice the area iac
displacement is augmented with mea- than the 4° average of persons with (Figure 16, B) . The upper trunk also the
surable arcs of pelvic and trunk mo- intact limbs. 45 follows a sequence of reciprocal for- tio:
tion. ward rotation in the horizontal plane.
Trunk The shoulder generally is higher on sin
Pelvis Throughout each stride the trunk also the side without the prosthetic limb, tab
A combination of sagittal and coronal experiences three-dimensional mo- although good walkers keep their the
plane tilting presents as figure-of-8 tion (measured at shoulder level). shoulders level. Arm swing was found tra
patterns of motion. The magnitude of Planar analysis shows the trunk fol- to be a balancing factor. Poorer walk- wi1
the three-dimensional motion varies lows a figure-of-8 pattern of lateral ers use greater arcs of pelvic motion. tro
with the quality of the walker (Figure and vertical motion. 46 Good walkers of
15). Anterior rotation and tilt accom- use a tight, symmetric motion pat- Muscle Control bet
pany the swinging limb. As the trunk tern, which remains within a 7-cm Jaegers and associates47 used surface wb
remains erect, compensatory lumbar area (Figure 16, A). Less able walkers EMG to identify the action of the su- tht

-10 -t--~~~~~~~--~~~~~~~~ -10 +-~~~~~~~--~~~~~~~-1
IS -15 0 15 -15 0 15
Lateral (cm) Lateral (cm)
A B
sfem-
1y KD:
-232.) Figure 16 One cycle of t runk motion recorded at shoulder level as a person wit h a transfemoral amputation walks on a level surface.
A. Good walker. B, Poor walker. (Adapted with permission from Tazawa E: Analysis of torso movement of trans-femoral amputees dur-
ing level walking. Prosthet Orthot Int 1997;2 1:129-140.)
perficial muscles controlling the hip. maximum. The signals with a likely fibers is indicated by the magnitude
The authors defined phasing as the cross talk origin were excluded. The of the muscles' EMG activity. The
interval of peak intensity excluding prolonged action of the gluteus maxi- prolongation of the rectus femoris
the lowest 12%, which was assumed mus (Figure 17, A) and gluteus me- through swing indicates the better en-
to include cross talk from adjacent dius (Figure 17, C) indicated the need d urance of shorter fibers.
musculature. This approach probably for vigorous support of the hip The EMG patterns for the trans-
was adequate for isolating the signals throughout single stance as well as femoral hip extensor, abductor, and
of the three large rectangular muscles limb loading. The change in the dom- flexor muscles are consistent with the
(erector spinae, gluteus maximus, and i11ant intensity of the transfemoral pattern of sustained residual limb dis-
gluteus medius) . All of the other mus- hamstrings to loading response (Fig- placement within the socket recorded
cles, however, are narrow rectangles in ure 17, B), rather than in the terminal with ultrasound.44
intimate contact w ith their neighbors, swing to decelerate the swinging limb, The relative effectiveness of the hip
15
and only the peak EMG could be ac- was further evidence of the need for muscles following amputation varied
cepted because of the ease of signal strong extensor muscle action at the significantly with the level of lin1b re-
travel among contiguous muscle tis- time the limb is accepting body moval, the extent of intramuscular
sue. This limitation applied to the weight. fatty degeneration, 48 and whether or
1 walks hamstrings (biceps femoris and semi- Several functional qualities are dis- not muscle lengtl1 was preserved by
f trans- tendinosus), the adductors (magnus played by the EMG pattern of the hip tenodesis at the time of the amputa-
and longus), and the hip flexors (sar- flexor muscles (Figure 17, D). Peak tion. For example, loss of the distal
torius and rectus femoris). Also, the activity of the adductor longus mus- third of the adductor magnus results
nt pat- depth of the primary hip flexor, the il- culature in preswing is consistent in a 70% reduction of the muscle's
:ie area iacus, made it lll:lavailable. Despite with the normal function of limiting moment arm. 35 The other adductor
1k also these limitations, significant informa- abduction as body weight is trans- muscles and the accessory hip flexors
:al for- tion was gained. ferred to the other limb. The intense have a similaT fate. Disruption of the
l plane. The peak signal intensity from sartorius EMG activity implies that iliotibial band impairs the gluteus
her on similar anatomic areas showed a no- the sartorius is the primary synergist maxim us. 48 Gottschalk and Stills35
climb, table increase in EMG intensity for all of the iliacus (which could not be recommend tenodesis of the adductor
> their the muscles of the subjects with sampled with surface electrodes). The magnus and tenodesis of the ham-
; found transfemoral amputations, compared phasing of the sartorius preswing string muscles, which has been found
r walk- with the signals of able-bodied con- through initial swing and a single to preserve normal tissue quality. On
1otion. trol subjects (Figure 17). Peak action high peak is consistent with the long three-dimensional MRI reconstruc-
of the residual limb muscles ranged fibers' unique capability to rapidly tions of the hip and tlugh muscles, sig-
between 50% and 75% of maximum, move the limb through a large arc of nificant atrophy has been identified in
surface whereas in the normal control subject hip flexion, whereas the limited experienced walkers with a w1ilateral
the su· the action did not exceed 25% of strength of rapidly shortening muscle transfemoral amputation of traumatic

100 100
1
75 >, x 75 E
~1 ~~ ~
en E
i I- 50
Gluteus max.imus - - i I- c
c:;;:
-:;;:
Adductor magnus • • • - - -
Normal -c:;;::;;: 50
0-
Biceps lemons - -
Se.mltendinosus - .... .
Normal
(I)
E
0
0 0
:;;: -
:::!; ~
0
w~
w~ 25 25
20 40 60 80 100 20 40 60 80 100
% Gait Cycle % Gait Cycle
A B Figu
in I
100 100 tion
sup1
~75 ~ 75 ing
>, )( x
as exte
'iii~
c
E
mer
Sartorius - - !, Gluteus medius/mininus - -
~ ~ 50 Rectos femoris ·- -·-····-· I\ ~ 50 Normal
limt
-
0
:::!;
-
:;;: 0
w ~ 25
Adductor longus ......
Normal
'\ll :;;:
0
~ 25
(Ad,
RE,
Me<
kne
0 0 Mee
0 20 40 60 80 100 0 20 40 60 80 100
c % Gait Cycle
D % Gait Cycle
mo
pre.
Figure 17 Muscular control of the hip during free-speed gait of individuals with a transfemoral amputation as measured by EMG.
A , Hip extensor muscles. B, Hamstring muscles. C, Hip abductor muscles. 0, Hip flexor muscles. (Adapted with permission from Jaegers
SM, Arendzen JH, de Jongh HJ: An electromyographic study of the hip muscles of transfemoral amputees in walking. Clin Orthop 1996; po"
328: 719-128.) sigt
gai1
mo
than normal. In contrast, the loading can
origin. The average atrophy of the pri- The ground-reaction force of the
mary hip extensors (gluteus maximus stance limb during weight acceptance force is not increased with the Spring-
fleJ<
and adductor magnus) was 38%, is higher than normal with most lite foot, which has a longer shank-
lim
whereas 60% atrophy characterized prosthetic feet. s t In meeting this foot spring.52 This difference is attrib-
added demand, the sound limb uses hip
the long muscles such as the ham- utable to the fact that tlle heel rise
increased ankle and knee motion,49 sub
strings, sartorius, and rectus femoris. elevates tlle body center when dorsi-
Even the noninvaded muscles (ilio- generates greater knee and hip exten- por
flexion is limited, which does not oc-
psoas and gluteus medius) displayed a sor moments, and creates higher 25~
cur with a flexible shank. Hence, the
22% loss. Hence, a transfemoral am- power at the hip.so The cause of this boc
free drnp of the higher body mass is Un<
putation significantly impairs muscle increased demand is the limited dor-
the stimulus for the greater loading ere.
control of the residual thigh. This fm- siflexion of the prosthetic foot. 52 For
force on the opposite side. me
ther explains why so few persons with example, the Seattle Lite foot, which
Midstance is normally a period of fen
amputations of dysvascular origin re- depends on int1insic flexibility, has
progressive dorsiflexion. The sound ilie
cover an effective gait. minimal dorsiflexion. This means
limb interrupts this action with in- mii
that most of the tibial advancement is
Other Limb Demand gained by prematme heel rise. In con- creased activation of its ankle plantar fin,
The gait of persons with transfemoral trast, the Springlite foot (Otto Bock flexor muscles to compensate for the for
amputation depends on several com- HealthCare) gains significant dorsi- delay in prosthetic knee flexion gu1
c 1 . . 37,49
pensatory functions by the sound limb flexion through its flexible shank. As a need ed 1or toe c earance m swmg. ten
to overcome the performance limita- result of these different prosthetic Recent data from studies of micro- pla
tions of prostl1eses.49 - 5 1 Each of these foot mechanics, the gJound-reaction processor-controlled hydraulic pros-
force dming weight acceptance (Fl ) tlletic knees have demonstrated a re- Cc
functions requires the sound limb to
exert greater effort than in normal generated by the Seattle Lite foot witl1 duction in the tendency of the ankle Wa
gait. All phases of stance are involved. its foot spring is significantly greater plantar flexor to vault, along witll a sis

150 50
100 ...c 40
E Q) 30
t1: ...
(J
Q)
50 n. 20
Q)
E 10
0
~
0
0-44 45.54 55·64 65-74 75-85 >85
Age group (years)
I 0 25 50 75 100
)0 % Gait Cycle Figure 19 Distribution of amputations in veterans discharged in 1992 by age group.
Figure 18 Support moment of the limbs

in persons with transfemoral amputa- significant functional contributions v1S1on between peripheral vascular
tions, compared with normal gait. The by the intact limb and trunk during disease and diabetes in the United
support moment is calculated as the mov-
ing sum of the limb's hip extensor, knee
each stride. The residual limb func- States.54-57 Less than 10% result from
extensor, and ankle plantar flexor motion is hampered by loss of muscuJa- trauma.
ments during the gait cycle. S = sound tme, lack of direct connection The age of most amputees now lies
limb, N =normal gait, P = prosthetic limb. between the human thigh and pros- between 55 and 75 years, and the
(Adapted with permission from Seroussi
thetic knee, and persistent limitations number reaching age 85 is in-
RE, Gitter A, Czerniecki JM, Weaver K:
Mechanical work adaptations of above- in the prosthetic foot. The sound limb creasing.54-59 Among the 5,180 veter-
knee amputee ambulation. Arch Phys augments transfemoral prosthetic gait ans discharged with an amputation in
Med Rehabil 1996;77:1209-1214.) by providing increased moments and 1992, the highest incidence of ampu-
100 powers generated at the ankle, knee, tations (44%) occurred in those age
and hip. 65 to 74 years. The incidence was sig-
more normal range of knee flexion in
Progress in prosthetic foot design nificantly lower for both the younger
preswing. has been directed toward increasing and older age groups (Figure 19). A
EMG.
At the end of stance, the push-off
,egers flexibility wnile preserving stability. similar relationship between age and
1996; power generated by the sound limb In conflict is the increased rigidity, amputation frequency was reported
significantly exceeds that of normal which may result from efforts to en- by the Nova Scotia Rehabilitation
gait. These increases in net ankle joint sure durability. A broad array of de- Centre.57 Of their 132 patients, 68%
moment and power indicate a signifi- signs is available to persons with an were age 60 to 79 years; there were
ading cant increase in work by the plantar amputation, but the advantages of markedly fewer amputations in the
>ring- flexor muscles of the sound limb. 49 each model continue to be offset by younger and older patient groups.
hank- The total support moment of the some disadvantages. None has signifi- Improved medical and smgical
limb is the sum of the ankle, knee, and cantly lessened energy cost, nor in- procedures also have permitted pres-
Lttrib-
hip moments. For the group of eight creased walking speed or symmetry. ervation of the knee iJ1 more patients.
'.il rise
subjects studied, the average total sup- Domrnance of one design over the As a result, the most frequent ampu-
dorsi-
port moment for the sound limb was others has yet to be demonstrated for tation level today is transtibial (63%),
ot oc-
25% greater than that exerted in able- persons dependent on a transfemoral and only 30% are transfemoral. The
:e, the bodied gair5° (Figure 18). This is an prosthesis, though tl1e trend favors exception to this pattern is seen in lo-
1ass is underestimation of the measured in- flexibility. cal programs emphasizing partial foot
>a ding crease in physiologic cost (45% per amputations. In the smvey of ampu-
meter walked) for persons with trans- tations among veterans, 44% were
iod of femoral amputations. 53 In contrast, Outcome within the foot, with a corresponding
sound the total support moment pattern is With the advances in limb salvage for reduction in transtibial procedw·es.55
.th in- minimal for the prosthetic limb. These the management of trauma and tu- The effects of a recent amputation
>lantar findings of greater moment patterns mors, the limbs of most young adults superimposed on the complications
for the for the sound limb present a strong ar- are preserved today; however, ampu- of aging and coexisting pathologies
flexion gumeJ1t for strengthening the hip ex- tation remains a common means of have challenged tl1e rehabilitation
og. 37,49 tensors of both limbs and tl1e ankle preserving the life and ambulatory programs that were designed for
micro- plantar flexors of the sound limb. ability of persons impaired by periph- young adults. The best approach to
pros- eral vascular disease and diabetes providing elderly patients with a
d a re- Conclusion mellitus. The cwTent etiology of prosthesis remains a challenge be-
e ankle Walking with a transfemoral prosthe- more than 80% of amputations is cause prosthesis use has a high failure
with a sis is an arduous task that requires dysvascular disease, with an equal di- rate among frail, older amputees. The

382 Section III: T he Lower Limb
footswitch contacts over many days that

TABLE 1 Stride Characteristics of Unilateral Lower Limb Amputation Gait in expands gait analysis to include the An i
Males
measurement of endurance.57 Among denc
Stride 48 subjects with unilateral amputa- nun:
No. of Age Velocity Length Cadence tions equally divided between the Pers·
Amputation patients (y) (m/min) (m) (steps/min)
transtibial and transfemoral levels, a 315
Traum atic
significant difference in walking en- erag
Transtibial 16·25·56 26 30 76 1.4 97
durance developed after the first 100 step:
Transfemo ra 110,37,3S,s4.&o.&1 11 0 35 54 1.3 85
days. From a common step pattern of tanc
Dysvascular
900 steps per day, the transtibial am- acfo
Syme procedure 56 14 57 54 1.1 98
p utees progressively increased their tion
Transtib ial4,9.10.1&.24.2&.s6 99 57 61 1.2 88 walking to 2,000 steps per day by 300 driv,
Transfemoral 56 13 60 36 1.0 72
days, while the transfemoral ampu- lie tJ
Normal 4 46 77 86 1.5 115 tees made no further gains. The acti,
progress of a small group of bilateral turn
transtibial amputees was similar to critt
effectiveness of medical management with normal physiologic health from that of the transfemoral amputees. caus
and rehabilitation have been assessed those in whom it is compromised Transtibial amputees older than age amp
from three primary aspects: survival, (energy and strength limitations). 65 years also showed the same limita- year
walking abilfry, and function. The multiple classes of limb loss re- tion as the transfemoral amputees. l\
Survival is significantly influenced main clinically pertinent, but only ami;
by comorbidity. 55 Among the 5,180 unilateral transtibial amputations, Function 65)
veterans who underwent amputation transfemoral amputations, and the The simplest assessment of an ampu- indc
in 1992, the calculated 6-year survival Syme ankle disarticulation are per- tee's ability to use a prosthesis is a incii
rate for those who had a forefoot am- formed with adequate frequency to mere "yes" or "no." Positive responses am:i:
putation was 50%, whereas cardiovas- permit group comparisons. To pro- were as high as 94% in Australia, 54 aids
cular disease reduced this prediction vide a perspective on the significance but 16% of amputees in Finland and 2243-i
to 30%, and renal disease to 20%. Di- of amputee disability, the stride char- Nova Scotia said "no." 56•64 A more thos
abetes did not show an adverse influ- acteristics of the male subjects with a discriminating criterion is the length Sev<:
ence on stu-vivaJ rate. lower limb amputation cited in the of time the prosthesis is worn per day. am:r
Walking ability is defined by the literatu.re have been tabulated (Table Use per day varied from 7 hours 54 to am:r
person's stride characteristics. Gait 1). Too few of the reports included 12 hours, 53 and the overall propor- den1
velocity is the basic measure, 60 -62 as data on female amputees to permit tion of the walking day was 60% to cam
persons spontaneously choose a walk- assessment of this group. There is 66%. This incidence increased to 79% vere
ing speed that is the optimum balance a significant difference in the peak for individuals with a transtibial am- gait
between progression and energy age range between traumatic (30 to putation, but was only 40% for those Ne~
cost.63 A good correlation with dis- 35 years) and dysvascular (65 to with transfemoral amputations. uniic
ability has been identified.60 •61 Also, 75 years) amputees. Few persons with Wearing the prosthetic limb part of of e
the amputee's stride characteristics transfemoral amputations of dysvas- the day (4 hours) was less frequent son:
define the walking ability associated cular origin regain an ability to walk, ( 12% to 25%). Age was fotmd to be
with the different classes of amputa- and those who do have the slowest ve- significant for the transfemoral am-
tion.53•62 Of the two basic compo- locity (36 m/min). This is barely half putees when an1bulatory indepen-
Re
nents of velocity, stride length and ca- of the walking speed used for a nor- dence was considered. Among indi- 1.1
dence, stride length delineates the mal stroli. 64 Trauma causes a similar, viduals in their seventh decade of life,
effectiveness of the limb mechanics but less severe, functional difference 44% walked without assistance, but
that contribute to progression. Ca- between transtibial and transfemoral the percentage dropped to 10% for
dence is less significant because it has amputees (76 m/min versus those in their eighth decade of life.
a voluntary quality, which allows 54 m/min). Only persons with trans- None of the five persons o lder than
some modification of walling speed. tibial amputations of traumatic origin 80 years was independent. 56 For trans-
The stride characteristics of ampu- have a walking speed within the tibial amputees, only reaching the age
tees are modified primarily by the ex- ranges used by able-bodied persons. of 80 years made a difference in am- 3. l
tent of limb loss and the etiology of This attests to their physiologic bulatory independence. I
the amputation. Subdividing lower health, which tolerates excessive en- Lifestyle evaluations almost always
limb amputation according to the ergy expenditure. assess the discharge residence, which
major etiologies of trauma and dys- Step cotmting with a microproces- is home for 90% of individuals with
vascular disease differentiates patients sor system that stores the number of lower limb amputation in countries

days that provide home adaptations. 54 •65 4. Powers CM, Boyd LA, Fontaine CA, cost of below-knee amputees wearing
: the An interesting assessment of indepen- Perry J: The influence of lower- six d ifferen t prosthetic feet. J Prosthet
nong dence at home was the measure of the ex.tremity muscle force on gait charac- Ortl10t 1992;4:63-75.
number of steps needed per day. 65 teristics in individuals with below- 17. Perry J, Antonelli D, Ford W: Analysis
>uta-
Personal care required an average of knee amputations secondary to of knee-joint forces during flexed-
the
vascular disease. Phys Ther 1996;76: knee stance. J Bone Joint Surg Am 1975;
~ls, a 315 steps and food preparation an av-
369-385. 57:961-967.
; en- erage of 727 steps, for a total of 1,042
5. Goh JC, Solomonidis SE, Spence WD, 18. Kapandji IA (ed): The Physiology of
t 100 steps per day. The average daily dis-
Paul JP: Biomechanical evaluation of Joints: Annotated Diagrams of the Me-
rn of tance walked was 560 m . The social
SACH and uniaxial feet. Prosthet chanics ofthe Human Joints. London,
I am- activities of persons with an amputa-
Orthot int 1984;8:147-154. England. E&S Livingstone, 1970,
their tion are limited by their inability to
6. Murphy EF: Lower-extremity compo- pp 88-89.
y 300 drive (25%) and inability to use pub-
nents, in Orthopaedic Appliances Atlas: 19. Lindahl 0, Movin A: The mechanics of
mpu- lic transportation (9%) . Most of their Artificial Limbs. Chicago, IL, American extension of the knee-joint. Acta
The activities are sedentary hobbies. Re- Academy of Orthopaedic Sw-geons, Orthop Scand l 967;38:226-234.
ateral turn to work is no longer an absolute 1960, vol 2, pp 129-261.
20. Otis JC, Gould JD: The effect of exter-
ar to criterion of rehabilitation success be- 7. Perry J, Boyd LA, Rao SS, Mulroy SJ: nal load on torque production by knee
utees. cause many individuals with an Prosthetic weight acceptance mechan- extensors. J Bone Joint Surg Am 1986;
n age amputation are of retirement age (65 ics in transtibial amputees wearing the 68:65-70.
imita- years and older). Single Axis, Seattle Lite, and Flex foot.
21. Barr AE, Siegel KL, Danoff JV, et al:
:es. Many individuals with lower limb IEEE Trans Rehabil Eng l997;5: Biomechanical comparison of the
amputation, whose average age is 283-289.
energy-storing capabilities of SACH
65 years, use a walking aid for both 8. Rao SS, Boyd LA, Mulroy SJ, Bon- and Carbon Copy I[ prostlietic feet
tmpu- indoor and outdoor ambulation. The trager EL, Gronley JK, Perry J: Seg- during the stance phase of gait in a
s is a incidence of persons with a transtibial ment velocities in normal and trans- person with below-knee amputa tion.
,onses amputation who walk without any tibial amputees: Prosthetic design im- Phys Ther 1992;72:344-354.
·alia,s4 aids is estimated between 15%59 and plications. IEEE Trans Rehabil Eng
22. Wagner J, Sienko S, Supan T, Barth D:
1d and 22%,65 compared with only 11 % for l 998;6:219-225.
Motion analysis of SACH vs Flex-
more those with transfemoral prostheses. 9. Sterling HM, Perry J, Grouley JK, Tor- Foot™ in moderately active below-
length Seventy-one percent of transtibial burn L: Rehab R&D Progress Report. knee amputees. Clin Prosthet Orthot
er day. amputees and 52% of transfemoral 1986; 19-20. 1987;11:55-62.
rs54 to amputees use one cane for indepen- 10. Skinner HB, Abrahamson MA, Hung 23. Geil MD: Energy loss and stiffness
ropor- dent walking. Dependence on two RK, Wilson LA, Effeney DJ: Static load properties of dynamic elastic response
iOo/o to canes or a frame walker indicates a se- response of the heels of SACH feet. prosthetic feet. J Prosthet Orthot 2001;
:079% Orthopedics l 985;8:225-228. 13:70-73.
vere limitation in walking ability, with
al am- gait velocities of 35 m/min or Jess. 11. Torburn L, Perry J, Ayyappa E, Shan- 24. Culham EG, Peat M, Newell E: Analy-
r those field SL: Below-knee amputee gait sis of gait following below-knee am-
New research is needed to address the
with dynamic elastic response pros- putation: A comparison of the SACH
:ations. unique needs of a growing population
thetic feet: A pilot study. J Rehabil Res and single axis foot. Physiother Can
part of of elderly, physiologically limited per-
Dev 1990;27:369-384. 1984;36:237-242.
·equent sons with lower limb amputation.
12. Van Jaarsveld HWL, Grootenboer HJ, 25. Lehmann JF, Price R, Boswell-Bessette
:I to be
De Vries J: Accelerations due to impact S, Dralle A, Quested K: Comprehen-
·al am-
1depen-
References at heel strike using below-knee pros- sive analysis of dynamic elastic re-
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g indi- l. Klute GK, Kallfelz CF, Czerniecki JM:
63-66. versus SACH foot. Arch Phys Med
: of life, Mechanical properties of prosthetic
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J Rehabil Res Dev 2001;38:299-307. 26. Doane NE, Holt LE: A comparison of
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2. Waters RL, Perry J, Antonelli D, Hislop the SACH and single axis foot in the
of life. 14. Gitter A, Czeruiecki JM, DeGroot DM: gait of unilateral below-k11ee ampu-
H: Energy cost of walking of ampu-
er than Biomechanical analysis of the influ- tees. Prosthet Orthot Int 1983;7:33-36.
tees: The influence of level of amputa-
,r trans- ence of prosthetic feet on below-knee
tion. J Bone Joint Surg Am 1976;58: 27. Snyder RD, Powers CM, Fontaine C,
the age 42-46. amputee walking. Am J Phys Med Perry J: The effect of five prosthetic
in am- Rehabil 1991;70:142-148. feet on the gait and loading of the
3. Munin MC, Espejo-De Guzman MC,
BoniJ1ger ML, Fitzgerald SG, Penrod 15. Powers CM: Rao S, Perry J: Knee ki- sound limb in dysvascular below-knee
t always LE, Singh J: Predictive factors for suc- netics in transtibial amputee gait. amputees. J Rehabil Res Dev 1995;32:
:, which cessful early prosthetic ambulation Gait Posture 1998;8:l-7. 309-315.
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ountries Res Dev 2001;38:379-384. Thomas S: Gait analysis and energy M, Zadravec M, Pierrynowski MR:

The role of the contralateral limb in amputees: User's verdict. Prosthet Sydney Hospital in 1988 1989. Disabi/
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Orthot Int 1990; 14:33-42. 41. Taylor MB, Clark E, Offord EA, Baxter 53. Waters RL, Hislop HJ, Perry J, An-
29. Perry J, Shanfield S: Efficiency of dy- C: A comparison of energy expendi- tonelli D: Energetics: Application to
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J Rehabil Res Dev 1993;30:137-143. putee using the intelligent Prosthesis motor disabilities: Energy cost of nor-
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30. Powers CM, Torburn L, Perry J,
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116-121. 54. Mayfield JA, Reiber GE, Maynard C,
foot design on sound limb loading in
Czerniecki JM, Caps MT, Sangeorzan
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BJ: Su rvival following lower-limb am-
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55. Anderson AD, Cummings V, Levine
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Human Walking. Baltimore, MD, Will- study of the motion of the residual 533-538.
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iruns & Wilkins, 1992, pp 85-88. 56. Holden JM, Fernie GR: Extent of arti-
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RC: The effects of walking velocity
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61. Skinner HB, Effeney DJ: Gait analysis
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82-89.
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swing p hase con trol for trans-femoral amp utees treated a t the Royal South ide11

Visual Analysis of Prosthetic Gait
to
)·
Susan L. Kapp, CPO
1or-
'lin
c,
zan
am-
,.
ne
rem-
ients.
Introduction
arti-
a- Clinicians frequently use visual gait Clinicians worldwide use OGA be- tritt4 has suggested that, for transtib-
analysis when evaluating the results of cause it is the least costly metl10d for ial prostheses, the load line on the
fitting with a prosthesis. Visual inspec- gait analysis, no specialized equip- prostlietic side should be 10 mm to
,opu- tion, also referred to as observational ment is required, no measuring de- 30 mm ahead of the knee. He used a
~: gait analysis, or OGA, is conducted vices encwnber tile amputee, and it is static laser line to identify the knee
while the patient is walking. The clinic not very time consuming. However, a position tllat best corresponded to
,very team verifies that the prosthesis is number of studies have shown that it biomechanical rules of alignment and
ampu- functioning well overall and that the is not as accurate or repeatable as found that experienced prosthetists
et patient has mastered prosthetic gait computerized gait analysis (CGA). 1•2 tended to obtain this result when per-
skills. The prosthetist looks for socket OGA is sufficient to make qualitative forming dynamic alignment trials us-
JO: problems, suspension shortcomings, judgments about various aspects of ing OGA.
mal alignment or component adjustment gait, but only CGA can provide quan-
ts.
mistakes, and errors in component tifiable results. Another significant
prescription. A therapist who special- shortcoming of OGA is that it is very Static Alignment
:ms ton
izes in amputee management looks for difficult to assess motion that crosses Prior to initial OGA, the prosthetist
ity
,inet-
subtle gait and postural errors that can multiple planes. Finally, only visible verifies that socket weight bearing
14. result in asymmetric, more energy- characteristics, such as kinematic and suspension are adequate and that
1alysis consuming ambulation. A physician variables, can be assessed with OGA. gross alignment and component ad-
15;64: who specializes in amputee rehabilita- To measure forces or to calculate justments are correct. During the
tion can readily detect changes in the torques generated, CGA is required. static phase of alignment, the lengtll
Ener- patient's physical condition and spot Prostl1etists receive specialized of the prosthesis is evaluated by pal-
nble JG important clues about more subtle training and practice in OGA, with an pating the iliac crests while weight is
lti- problems such as errors in the thick- emphasis on optimizing prostlietic applied to both limbs even ly. During
' 1994, ness of the prosthetic socks being alignment and component adjust- static standing, the prosthetic socket
worn. ments based on OGA plus amputee should be slightly flexed such that the
1ner OGA is based on visual assessment feedback regarding forces, which can- patient can stand comfortably witl1-
\MG of motion to identify kinematic asym- not be observed. Despite its inherent out excessive lumbar lordosis. Weight
fast metries in all three planes. Effective subjectivity, evidence is emerging that should be borne evenly along the sole
'2-280. OGA requires a tJ1orough knowledge experienced prosthetists tend to reach of the shoe, and the pylon should not
lfk- of the biomechanics of gait and the similar end points in dynamic align- have an excessive medial or lateral
Lll1C· functional features of each component ment based on OGA. Geil3 compared lean. The prosthetic foot should
,wing of tile prosthesis. The overall goal of the results of five alignments done by match the heel height of the shoe.
Prosthet OGA is to verify that the amputee's five prosthetists using visual analysis. This relationship is confirmed when
gait is smooth, symmetric, and confi- He concluded that th.e consistency the top of the prostlietic foot is paral-
al walk-
dent. Any deviations from this goal re- among practitioners with varying lev- lel to the floor. The external rotation
1t home.
quire further investigation and are ac- els of experience suggests that auto- of the prosthetic foot should closely
0.
ceptable only if the cause has been mated alignment is probably feasible match that of the sound side. In a
identified and cannot be rectified. but may not be necessary. Blwnen- transfemoral prosthesis, the knee cen-

ter generally should fall 6 mm behind ment in each plane to identify specific adjustment of the prosthetic compo-
a line connecting the trochanter and
the ankle. This measurement will vary
problems. Areas to observe include
the foot/ground relationship during
nents is modified to reduce their
magnitude. G
somewhat, with knees offering more stance, symmetry of steps, prosthetic The study guides shown on pages
inherent stability when placed on or and nonprosthetic knee motion, and 388 through 394 summarize com-
slightly anterior to this reference line. pelvic motion (Trendelenburg) . Fi- monly observed transtibial and trans-
nally, patient feedback is sought re- femoral gait deviations and typical
garding limb comfort, perceived hip
Dynamic Alignment and knee forces, and overall effort re-
prosthetic and patient causes. The
study guides also indicate in which
Once the gross alignment, length, and quired to walk.
plane the deviation is best viewed.
adjustments have been verified, then Rancho Los Amigos National Re-
They are intended to be a summary of
[
dynamic alignment trials can begin by habilitation Center has developed a
the most commonly encountered [
having the patient ambulate within format to record observational gait
clinical problems but not an exhaus- T
parallel bars. If tl1e socket of the pros- analysis results (Figure 1). The spe-
cific sequence of decision-making is tive listing of all possible deviations
thesis is securely attached to the
alignment components and the pa- less important than approaching or causes. For most problems, OGA
tient is able to ambulate safely after OGA in a systematic and comprehen- can identify the deviation, but further p
gait has been optimized within the sive manner. investigation is required to determine
parallel bars, dynamic alignment may The first step is to observe gross the causes and therefore the remedy.
continue with free walking. The pa- gait. Most gait deviations are best vi- Intermittent deviations are often due
tient is viewed in both the sagittal and sualized from the side, usually with to inconsistencies in the patient's gait
coronal (frontal) planes as he or she the prosthesis closest to the observer. and indicate the need for more gait E
walks. Each phase of gait is evaluated Experienced clinicians tend to stand training, more time to adapt to a new
for optimum alignment, and any de- at right angles to the line of progres- prosthesis, or both.
viation is noted and corrected. By an- sion near the middle of the walkway,
l
alyzing each phase of gait, the ob- to see sagittal plane motion in isola-
server can systematicaUy identify tion. Then, with the clinician standing References
elements that are less than optimal. behind the patient, coronal plane l. Rietman JS, Postema K, Geertzen JHB:
Once the alignment is fine tuned, the problems can be observed as the pa- Gait analysis in prosthetics: Opinions,
patient will ambulate with the most tient moves away from and toward ideas and conclusions. Prosthet Orthot
energy-efficient gait. For new ampu- the observer. Finally, transverse plane Jnt2002;26:50-57.
tees, recovery from the debilitating ef- problems are noted. 2. Krebs DE, Edelstein JE, Fishman S:
fects of surgery and gait training may The second step includes observa- Reliability of observational kinematic
take several months, so repeated dy- tion of kinematics at each body seg- gait analysis. Phys Ther 1985;65:
namic alignment trials will be neces- ment. Slow motion analysis of digital 1027- 1033.
sary. For experienced amputees, dy- video is very helpful in isolating 3. Geil MD: Variability among practitio-
namic alignment can proceed more phases of gait and clarifying devia- ners in dynamic observational align-
quickly. For active individuals, dy- tions but has not been shown to result ment of a transfemoral prosthesis. J
namic align,ment may include obser- in more accurate OGA. Attempts to J Prosthet Orthot 2002; 14:159-164.
vational gait analysis on a treadmill or measure angles between limb seg- 4. Blumentritt S: A new biomechanical
jogging track. ments based on video images alone method for determination of static
Clinicians must first evaluate over- have never been validated. Once gait prosthetic alignment. Prosthet Ort/wt
all movement of the body as a whole deviations are detected, their cause Int 1997;21:107-113.
and then focus in on each body seg- can be inferred, and the alignment or
Fig
ne:
an,
Chapter 31: Visual Analysis of Prosthetic Gait 387
)0-
.eir
GAIT ANALYSIS: FULL BODY
ges RANCHO LOS AMIGOS NATIONAL REHABILITATION CENTER PHYSICAL THERAPY DEPARTMENT
ru-
ns-
ical Reference Limb:
Che
.ich
LO RD
,ed.
Major Deviation Major
r of
red
Minor Deviation LR MSt TSt PSw ISw MSw TSw Problems:
IUS- Trunk
ons Lateral Lean: R/L (WA)
GA
1 Rotates: B/F Weight
:her Pelvis Acceptance
nne
edy. Lacks Forward Rotation
due Lacks Backward Rotation
gait Excess Forward Rotation
gait Excess Backward Rotation
new Ipsilateral Drop
Contralateral Drop (SLS)
Hip Flexion: Limited Single Limb
Excess Support
Past Retract
rHB: Rotation: IR/ER
ons, AD/ ABduction: AD/ AB
that
Knee Flexion : Limited
Excess
,:
Wobbles
.a tic
Hyperextends (SLA)
Extension Thrust Swing Limb
Varus/Valgus: Vr/VJ Advancement
itio-
Excess Contralateral Flex
gn-
Ankle Forefoot Contact
Foot Flat Contact
cal Foot Slap
ic Excess Plantar Flexion
that Excess Dorsitlexion
Inversion/Eversion: Iv/Ev Excessive UE
Heel Off Weight Bearing D
No Heel Off
Drag
Contralateral Vaulting Name
Toes Up
Inadequate Extension Patient#
Clawed/Hammered: Cl/Ha
© 2001 LA REI. Rancho Los Amigos National Rehabilitation Center, Downey, CA 90242 Diagnosis
Figure 1 This table is used to record OGA in a systematic and comprehensive manner. (Reproduced with permission from the Pathoki-
nesiology Service and the Physical Therapy Department (eds): Observational Gait Analysis. Downey, CA, Rancho Los Amigos Research
and Education Institute, 2001, p 72.)
Transtibial Gait Deviations Mi

Be
(study guide)
Initial Contact (Heel Strike) Deviation Possible Causes

Best viewed from the side Knee ful ly extended • Faulty suspension, does not maintain
knee in 5° to 10° of flexion
• Insufficient preflexion of the socket
• Foot too anterior
Knee excessively flexed (greater than • Faulty suspension (maintains knee in
10°) greater than 10° of f lexion)
• Possible flexion contracture
.,
G,
•
Unequal stride length • Faulty suspension (may limit range
of motion of knee)
• Poor gait pattern •
•
Goals
• Kn ee maintained in 5° to 10° of flexion
• Stride length equal to that of sound side
Loading Response Deviation Possible Causes T

(Heel Strike to Foot Flat)
Knee flexion is not smooth or Weak quadriceps B
Best viewed from the side controlled, may look "jerky"
Knee flexion is abrupt and • Foot too posterior
uncontrolled • Socket too flexed (foot is excessively
dorsiflexed)
• Heel on shoe too high
• Plantar flexion bumper or heel
wedge in foot too firm
• Shoe does not allow heel cushion to
compress sufficiently
Knee remains extended and patient • Foot too anterior
"rides" the heel through to • Insufficient socket flexion (foot
midstance plantar flexed)
• SACH heel too soft (if greater than
Goals 3/a inch)
• Smooth knee flexion to approximately • Heel on shoe too low
20° • Excessive use of knee extensors
• Approximately 3/a-in heel compression (poor gait pattern)
• No piston action
Piston action, patient may be • Suspension too loose
dropping too deeply into the socket • Not enough prosthetic socks
(best viewed in the coronal plane as • Faulty socket modifications (not
patient walks away from observer) enough support under medial t ibial
f lare or patellar tendon)

Midstance Deviation Possible Causes

Best viewed from the front Pylon leans medially • Too much adduction in the socket
• Foot may be outset
\
Pylon leans lateral ly • Not enough adduction in the socket
/
• Foot may be inset
~ Y:z-in varus moment not apparent (for • Foot relatively outset

some patients this may be desirable
to reduce torque)
IL.. l
Varus moment excessive (greater than • Foot too inset
":.~ Y:z inch is never desirable)
Less than 2 inches between feet at

• Medial-lateral socket dimension too
wide
• Foot inset (narrow base gait)
-
.; ~ midstance
~-- " Greater than 4 inches between feet at • Foot too outset
Goals midstance
• Pylon vertical
• Socket displaced laterally by about Y:z Lateral trunk bending at midstance to • Prosthesis too short
inch (duplicates varum moment at mid- the prosthetic side • Residual limb pain (patient leans
stance) laterally to reduce torque)
• 2 to 4 inches between medial side of the • Prosthesis too long
feet (as the swing foot passes the stance • Foot too outset
foot)
• No excessive lateral trunk bending
Terminal Stance (Heel-Off) Deviation Possible Causes
Best viewed from the side Heel-off occurs early and abruptly. • Toe lever arm too short due to
The patient appears to "drop off" excessive posterior position of the
the foot at the end of stance phase. foot
• Foot may be excessively dorsiflexed
(socket is in too much flexion)
Heel-off is delayed. The pat ient's knee • Toe lever arm is too long due to
may tend to hyperextend. The excessive anterior placement of the
patient may describe a feel ing of foot
"walking uphill." • The foot may be plantar flexed
(insufficient socket flexion)
Goals
• Heel-off should occur smoothly and
effortlessly prior to initial contact on the
sound side
• Immediately after heel-off, the knee
should begin to flex in preparation for
toe-off

Preswing (Toe-Off) Deviation Possible Causes

Best viewed from the side "Drop off" (patient appears to fall • Foot too posterior
too quickly to the sound side) • Foot too dorsiflexed (excessive
socket flexion)
Socket drops away from the residual • Suspension too loose (for
limb (evident when the anterior supracondylar sockets) or
socket gaps or the posterior indentation located too high above
proximal socket brim drops distally the femora l condyles (for patellar
in relation to the popliteal region) tendon-bearing supracondylar-
suprapatellar sockets) lnii
• Patient may not be wearing enough
prosthetic socks Be:
Goals
• Smooth transfer of body weight to the
sound side
• Socket rema ins adequately suspended
as swing phase is initiated
Ge
Swing Deviation Possible Causes •s
• f
Best viewed from the side Foot "whips" medially or laterally • Cuff suspension tabs not aligned • E
during initial swing evenly
• Prosthetic socket rotated medially or
laterally with respect to the line of
progression
Prosthetic foot touches the floor • Prosthesis too long
during midswing • Suspension too loose
• Knee flexion may be limited by the
socket or suspension system
• Muscle weakness or lack of gait
training
Goals
• During initial swing (viewed from the
posterior), the heel of the foot should
accelerate smoothly with no tendency
to "whip" medially or laterally.
• During midswing, the prosthetic foot
should swing through without touching
the floor. The patient should not have
to exert extra effort to ensure foot
clearance.

Chapter 31: VisuaJ Analysis of Prosthetic Gait 391
Transfemoral Gait Deviations

(study guide)
Initial Contact (Heel Strike) Deviation Possible Causes

Best viewed from the side Knee instability • Knee set too far anterior
• Excessive resistance to plantar
flexion (plantar flexion bumper or
heel cushion too firm)
• Increased shoe heel height causing
an anterior leaning pylon
• Initial socket f lexion insufficient to
give hip extensors a biomechanical
advantage
• Patient may have weak hip
extensors
Unequal step length (short prosthetic • Painful socket causes patient to
side step) quickly transfer weight to sound
side
• Insufficient knee friction or
Goals extension aid can cause excessive
• Smooth controlled plantar flex ion heel rise resulting in uneven timing
• Knee extension stability • Unstable knee
• Equal step length • Patient insecurity, lack of balance, or
muscle weakness
>r Foot slap (rapid toe descent) • Plantar f lexion bumper or heel
cushion in foot too soft
• Patient forces heel compression to
ensure knee stability

Loading Response Deviation Possible Causes Ter

(Heel Strike to Foot Flat)
External foot rotation • Plantar flexion bumper or heel
Best viewed from the side cushion in foot too firm
• Excessive toe-out
• Socket rotation from loose fit
• Socket rotation as a resu lt of tight
medial/posterior wall angle
• Patient has poor muscle control
Goals Go
• Foot remains on the line of progression • c
during plantar flexion
• I
Midstance Deviation Possible Causes Pr

Best viewed from the side Abducted gait (prosthesis held away • Pubic ramus pressure w
from midline throughout the gait • Pain at the distal lateral femur de
cycle) • lateral wall not shaped to provide
adequate femur support
• Prosthesis too long
• Excessive socket abduction built into
the prosthesis
• Pelvic band position too far from
ilium
• Patient has weak or contracted
abd.uctors
• Patient insecurity, lack of balance, or
habit
lateral trunk bending • Prosthesis too short
• Excessive foot outset
• Insufficient socket adduction G
Goals • Wide medial-lateral socket
• Vertical pylon dimension
•
• Narrow-based gait, 2 to 4 inches be- • lateral wall not shaped to provide
tween medial side of the feet (as the adequate femur support
swing foot passes the stance foot) • Pubic ramus pressure
• No excessive lateral trunk bending • Pain at t he distal lateral femur
•
• Patient has weak or contracted hip
abductors
• Patient has short resid ual limb
Toe rotation does not match sound • Improper foot rotation
side

Terminal Stance (Heel-Off) Deviation Possible Causes

Best viewed from the side Pelvic rise (hill climbing) • Toe lever too long
Drop off (excessive pelvic drop with • Toe lever too short
forward progression)
Excessive lumbar lordosis • Insufficient initial socket flexion
• Improperly shaped posterior wall
causing painful ischial weight
bearing
• Patient has hip f lexion contracture
• Patient has weak hip extensors or
weak abdominal muscles
• Patient has short residual limb
decreasing the functional lever arm
Goals
• Center of gravity follows smooth arc
without perceptible rise and fall of head
• Normal step length on sound side
without excessive lumbar lordosis
Preswing (Toe-Off) Deviation Possible Causes

Whips best viewed from the back; other Medial whip (abrupt medially • Knee axis in excessive external
deviations best viewed from the side directed motion of the heel with rotation
external rotation of the knee) • Socket donned w ith too much
external rotation
Back view • Socket contours do not adequately
accommodate contracting muscles
• Silesian belt worn too tightly
• Patient has weak limb musculature
Lateral whip (abrupt laterally directed • Knee axis in excessive internal
motion of the heel with internal rotation
rotation of the knee) • Socket donned with too much
internal rotation
Back view • Socket contours do not adequately
accommodate contracting muscles
• Patient has weak limb musculature
Goals Socket drops away from the residual • Inadequate suspension
• Hip, knee, and foot swing through on limb
the line of progression
• Smooth hip and knee flexion with Side view
"quadriceps-like" control
Inadequate or delayed knee flexion • Excessive mechanical resistance to
• Heel rise equal to sound side
knee flexion
• Socket remains secure on the residua l Side view • Prosthesis aligned with too much
limb
stability
Uneven heel rise • Incorrect resistance to knee flexion
• Incorrectly adjusted extension bias
Sagittal view • Patient may forcibly f lex hip or give
too little or no hip flexion

Initial and Midswing Deviation Possible Causes

Circumduction best viewed from t he Circumduction (flexion, abduction, • Excessive mechanical resistance to
back; vaulting best viewed from the side and external rotation fo llowed by knee flexion
adduction; prosthesis swings on a • Prosthesis aligned with too much
laterally curved line) stability
• Extension bias too strong
Back view • Prosthesis too long
• Medial brim pressures
• Inadequat e suspension
• Patient lacks confidence or has
inadequate hip flexion
Vaulting (rising on the toe of the • Prosthesis too long
sound side to clear the prosthetic • Excessive mechanical resistance to
foot) knee flexion
• Prosthesis aligned w it h too much
Side view stability
• Extension bias too strong
• Inadequate suspension
Goals
• Patient habit
• Center of gravity reaches the summit on
its smooth, rhythmic path over t he Int
prosthetic foot
Mea:
expe
able
ing ·
logic
Terminal Swing Deviation Possible Causes basi,
Best viewed from the side Excessive terminal impact • Insufficient knee friction rele,
• Extension bias too strong deta
• Worn or absent extension bumper
• Patient strongly and deliberately put2
ext ends hip to ensure knee wa!J.
extension at initial contact the
Unequal step length (long prosthetic • Insufficient initial socket flexion to ta tic
side step) accommodate a hip flexion ate I
contracture
and
hab
En
Goals
• Smooth and noiseless deceleration to
M1
f ull extension Aftt
• Equal step length
con
rat~
reac
ene
car,
ratt
log
Ste,
The
tin,
dw
AE
M1
Du
obi
ces

Energy Expenditure of Walking in
Individuals With Lower Limb
Amputations
Robert L. Waters, MD
Sara]. Mulroy, PhD, PT
Introduction
Measurement of physiologic energy exercise workload. During mild or for sudden and short-term strenuous
expenditure has proved to be a reli- moderate exercise, the 0 2 supply to activity. Anaerobic oxidation is lim-
able method of quantitatively assess- the cell and the capacity of aerobic ited, however, by the individual's tol-
ing the penalties imposed by patho- energy-producing mechanisms are erance for acidosis resulting from the
logic gait. This chapter outlines the usually sufficient to satisfy adenosine accumulation of lactate. The point of
basic principles of exercise physiollogy triphosphate (ATP) requirements, and onset of anaerobic metabolism is her-
relevant to human locomotion and exercise can be sustained for a pro- alded by a rise in the serum lactate
details the impact of lower limb am- longed time without the individual level, a drop in pH, and a rise in the
putation on the energy expenditure of reaching an easily definable point of ratio of expired carbon dioxide (C0 2 )
walking. The chapter also compares exhaustion. 1 During more strenuous to inspired 0 2 . 2
the effects of various levels of ampu- exercise, both anaerobic and aerobic
tation and patients' capacity to toler- oxidation processes occur. From a Measurements Used in
ate the increased energy requirements practical standpoint, the anaerobic Metabolic Studies
and examines the effectiveness of re- pathway provides muscle with an im- Table 1 lists terms and units used in
habilitation interventions. mediate supply of additional energy metabolic studies.
Energy Sources and

TABLE 1 Terms and Unit s Commonly Used in M etabol ic Studies
M easurement
Basal metabolic rate (BMR) The minimum level of energy required to sustain the body's
After several minutes of exercise at a vital functions in the waking state.
constant submaximal workload, the Calorie A gram-calorie is t he amount of heat energy requi red to raise 1 g of water 1•c.
rate of oxygen (0 2 ) consumption A kilogram-calorie is the amount of heat energy required to ra ise 1 g of water
reaches a level sufficient to meet the 1,ooo•c. Because of the equivalence between caloric expenditure and 0 2 consumption
during aerobic activities (5 g-calories = 1 ml 0 2 consumed), t he terms energy
energy demands of the tissues. The expenditure and 0 2 consumption can be used interchangeably in this context.
cardiac output, heart rate, respiratory 0 2 cost The amount of energy required to perform a task. During level walking, the 0 2
rate, and other parameters of physio- cost is the amount of 0 2 consumed per kilogram of body weight per unit distance
logic workload also plateau, and a traveled (mUkg·m), or rate of 0 2 consumption divided by walking speed. Also called
physiologic work.
steady-state condition is achieved.
0 2 pulse The rate of 0 2 consumption divided by t he heart rate. Indicates the exercise
The rate of 0 2 consumption at this efficiency of t he active muscle.
time reflects the energy expended
Rat e of 0 2 consumpt ion Equal to t he milliliters of 0 2 consumed per kilogram body
during the activity. weight per minute (mUkg·min). Also called power requirement.
Respiratory Exchange Ratio (RER) The ratio of C0 2 production to 0 2 consumption under
Aerobic Versus Anaerobic exercise conditions. An RER greater than 0.90 is indicative of anaerobic activity, and
Metabolism an RER greater t han 1.00 is indicative of severe exertion.
Vo2max The highest rate of 0 2 consumption attained during exercise of large muscle
During continuous exercise, both aer- groups at sea level. The higher t he 0 2 uptake, t he greater the aerobic energy output.
obic and anaerobic metabolic pro- Vo2 max is an indicator of physical f it ness. Also called maximal aerobic capacity.
cesses may occur, depending on the

Units of Energy Maximal Aerobic Capacity sence of cardiac disease, a linear rela- occur,
The energy units used in metabolic The maximal aerobic capacity tion exists between the rate of 0 2 volurr
stuclies are the gram-calorie (cal) and (Vo 2 rnaJ is the highest 0 2 uptake an consumption and heart rate. At a crease
the kilogram-calorie (Kcal). Because individual can attain dtuing physical given rate of 0 2 consumption, higher rate a
the direct measmement of heat pro- work while breathing air at sea level. 1 heart rates are associated with lower for 3
duction in subjects while they exercise It is the single best inclicator of physi- limb exercise than with upper limb in a :
exercise. 1 The ratio of 0 2 uptake to decre,
is impractical, caloric consumption is cal fitness. 3 Generally an individual
calculated inclirectly based on the vol- heart rate is called the 0 2 pulse, an volun
will reach Vo 2 rnax within 2 to 3 min-
ume of 0 2 consumption and C0 2 indicator of cardiovascular exercise In ad<
utes of exhausting work.
efficiency. A higher 0 2 pulse value in- respir
production. Age influences the Vo 2 rnax· Up to
dicates greater exercise efficiency. De- Of ffi(
approximately age 20 years, the
Units of Power and Work conditioning, which can be caused by suppl
Vo 2 max increases. Thereafter, the
inactivity or disease that impairs the creasi
The terms power and work describe Vo 2max declines, primarily because of
delivery of 0 2 to the cells, decreases A
energy expenditure. The power re- a decrease in both maximum heart
the 0 2 pulse value. many
quirement of an activity is the same rate and stroke volume, and also be-
as the rate of 0 2 consumption, which cause inclividuals usually exercise less putat
Training
is defined as milliliters of 0 2 con- as they age. Physi
A physical conclitioning program can 0 2 pi
sumed per kilogram of body weight Because body size and composi- increase aerobic capacity by increasing b
per minute (mL/kg·min). Physiologic tion affect the amount of 0 2 con- ing several factors: carcliac output, the
work is the amount of energy resumed, Vo 2max is clivjded by body dis ea
capacity of the cells to extract 0 2 ease
quired to perform a task. weight to enable comparisons be- from the blood, the hemoglobin level,
Physiologic work (0 2 cost) during tween subjects. Differences in body cular
and muscle mass (hypertrophy). All mon
level walking is defined as the amount composition and hemoglobin level of these changes lead to increased fat
of 0 2 consmned per kilogram of body account for a higher Vo 2max in men the fi
utilization as the primary source of
weight per unit distance traveled than in women. Although the Vo 2 max energy.2 As a result, less lactate is
(mL/kg·m) and is determined by di- per kilogram of fat-free body mass is formed during exercise, and endur- Rei
victing the rate of 0 2 consumption by not significantly different between
the speed of walking. By comparing men and women, the absolute Vo 2 max
ance is increased. Other effects of aer- ME
obic training include a decrease in the
the energy cost of pathologic gait is 15% to 20% higher in men because resting and submaximal heart rates; The I
with the corresponding value for nor- men generally have lower body fat lowered blood pressure; and an in- mini
mal gait, it is possible to determine and higher hemoglobin levels than do crease in stroke volume and, there- to SU
the gait efficiency. women. 1' 2 Similarly, the Vo2max> when fore, cardiac output. the '
The rate of 0 2 consumption relates normalized by body weight, is 10% to Aerobic fitness level as a result of port:
to tbe level of physical effort; the 0 2 15% higher in children age 6 to 12 training, muscle fiber type, capillary bod)
cost is a measurement of the total en- years than in a 20-year-old adult. 4 density, and changes in the oxidative lean
ergy required to perform the task of The Vo 2max also depends on the capabilities of the muscles determines cour
wall<ing. Oxygen cost will be higher type of exercise performed. The 0 2 the percentage of the Vo 2max that can BMI
either when 0 2 consumption is demand is directly related to the mus- be sustained during endurance exer- BMI
higher at a normal walking speed or cle mass involved; therefore, the cise without triggering anaerobic me- ever
when the walking speed is lower at a Vo 2 max dming upper limb exercise is tabolism.2•7 The contribution of hoo,
normal rate of 0 2 consumption. In lower than during lower limb exer- anaerobic metabolic pathways nor- age
the latter case, the patient will not excise. For any given workload, how- mally begins when the 0 2 uptake char
perience physical stress or fatigue, and ever, heart rate and intra-arterial reaches between 55% and 65% of the sulti
the high energy cost is not clinically blood pressure are higher in upper Vo 2 max in healthy, untrained subjects, mus
significant. lin1b exercise than in lower limb exer- but in highly tnined athletes, it may off,
cise.5 The reduction in available mus- not begin until 0 2 uptake exceeds 1
Respiratory Exchange Ratio cle mass that occurs with lower limb 80% of the Vo2max·S· • • Experienced sam
The respiratory exchange ratio (RER) amputation reduces the individual's endurance athletes tend to compete at whe
is the ratio of C02 production to 0 2 Vo2 max> with greater decrements at exercise levels just above the point of sitti
consumption under exercise concli- higher amputation levels.6 onset of blood lactate acctunula- ll1Cr
tions.2 Sustained strenuous exercise tion. 12,13 eva1
resulting in an RER greater than 0.90 Heart Rate A sedentary lifestyle has the oppo- by'
is indicative of anaerobic activity.' A Increased heart rate, or tachycarclia, is site effect of physical conditioning on of
ratio greater than 1.00 is indicative of the symptom most closely associated Vo 2max· ' 4 • 15 Not only does atrophy of 3.3
severe exertion. with strenuous exercise. In the ab- peripheral musculoskeletal structures rest

Chapter 32: Energy Expenditure of Walking 397
la- occur, but there is a decline in stroke tromyographic studies that demon- (1.165 m versus 1.42 m) because of
volume and cardiac output and an in- strated that minimal m uscular activ- their smaller stature, whereas cadence
02
a crease in resting and exercising heart ity is required for normal is faster ( 120 steps/min versus
lier rate as a result of inactivity. Bed rest standing. 19•20 In the normal individ- 112 steps/min) to compensate for the
.,,er for 3 weeks has been shown to result ual, postural reflexes balance align- shorter stride .
mb in a 27% decrease in the Vo 2 max by ment of the center of gravity close to
decreasing cardiac output and stroke the center of rotation of the hip, knee, Walking at a Controlled
to
an volume and affecting other factors.
15
and ankle joints so that the muscle Speed Versus a
:ise In addition, any d isease process of the forces required for standing are mini- Self-Selected Speed
in- respiratory, cardiovascular, muscular, mal. This is another example of en- Although it is convenient to measure
)e- or metabolic system that restricts the ergy conservation in human lower energy expenditure at a controlled
. by supply of 0 2 to the cells will also de- limb design. walking speed on a treadmill, this ap-
the crease the Vo 2 ma,c proach has several disadvantages.
1ses A special problem confron ting First, the CWS varies greatly in differ-
many older patients with vascular am-
Normal Walking
ent patient populations depending on
putations is Limited exercise ability. Range of Customary the extent of disability. Also, patients
Physical work capacity, Vo 2 max• and Walking Speeds with gait disabilities may have diffi-
can 0 2 pulse are reduced not only by ag- Most adults prefer to walk at speeds culty adjusting to walking on a tread-
easing but also by commonly associated from 1.0 to 1.67 m/s (60 to 100 mill. For these reasons, most investi-
the diseases such as arteriosclerotic dis- m/min). 21 -23 In a study of adult pe- gators prefer to conduct testing on a
02 ease of the heart and peripheral vas- destrians age 20 to 60 years who were track, allowing patients to select tl1eir
:vel, cular system. Diabetes, which is com- unaware they were observed, the own CWS.
All mon in vascular amputees, increases mean walking speed for men, 1.37
l fat the frequency of these disorders. mis (82 m/min), was significantly Energy Expenditure at the
e of
e is
higher than that for women, 1.23 m/s cws
(74 m/min).21 Similar values were ob-
:lur- Resting and Standing tained in energy expenditure studies
At the CWS, the rate of 0 2 consump-
tion for adults age 20 to 59 years and
aer- Metabolism performed on an outdoor, circular those age 60 to 80 years does not dif-
Ithe
The basal metabolic rate (BMR) is the track when subjects were instructed fer significantly, averaging 12.1 and
ates;
minimum rate of energy use required to select their natural customary 12.0 mL/kg·min, respectively23 (Table
in-
to sustain the body's vital functions in walking speed (CWS).23 Patients in 2). The rate of 0 2 conswnption is
1ere-
the waking state.2 The BMR is pro- this study were also tested at their higher in teenagers and children, av-
portional to the surface area of the customary slow and fast speeds. The eraging 12.9 and 15.3 mL/kg·min, re-
It of
body as well as to the percentage of customary slow, normal, and fast spectively. Expressed as a percentage
llary
lean body mass, and this in part ac- walking speeds in adults age 20 to 59 of the Vo 2 max• the rate of 0 2 con-
ative
counts for a 5% to 10% difference in years ranged from approximately 0.62 sumption at the CWS requires ap-
lines
BMR between women and men. The to 1.65 mis (37 to 99 m/min). 23 proximately 28% of the Vo 2 max of an
: can
BMR decreases approximately 2% for At speeds greater than 100 m/min, untrained normal subject age 6 to 12
exer-
me- every 10 years of age, through adult- the individual chooses whether to years, 32% of the Vo2 max of an adult
of hood.2 This reduction in BMR with walk or to run. Thorstensson and age 20 to 59 years, and nearly 48% of
nor- age coincides with the progressive Roberthson 24 found the transition tl1e Vo 2 max of an adult age 60 to 80
>take change in body composition that re- point between walking and running years.4 •25 "27 The RER is less than 0.85
f the sults in a lower proportion of lean in men occurred at an average of for normal subjects of all ages at their
jects, muscle mass and a higher percentage 1.88 mis (113 m/min) , with a ten- CWS, indicating anaerobic metabo-
may of fat and bone. dency for longer-legged men to make lism is not required.23
:eeds The BMR is approximately the the transition at a higher speed. Run- In a study of sedentary and active
:need same as the resting metabolic rate ning becomes more efficient than adt1lts, the older subjects (age 66 to 86
ete at when a person is recumbent. 16 In the walking at speeds greater than ap- years) had a lower rate of 0 2 con-
nt of sitting position, 0 2 uptake is slightly proximately 2.22 m/s (133 m/min).22 swnption at their CWS than did the
nula- increased. 17 Quiet standing further el- In children the CWS is slower than younger subjects (age 18 to 28 years)
evates the rate of 0 2 consumption in adults, averaging 1.17 m/s for the sedentary groups only,
)ppo- by approximately 22%, to an average (70 m/min) for children age 6 to 12 whereas tl1e 0 2 consumption values
1g on of 3.5 mL/kg·min for men and years and 1.22 m/s (73 m/ min) for for the active groups were similar
hy of 3.3 mL/kg·min for women. 18 These teenagers. 23•25 Stride length in chil- across age. This may have been the re-
:tures results are in agreement with the elec- dren is shorter than in adults sult of a purposeful effort to keep ex-

than
TABLE 2 Energy Expenditure at CWS and FWS at Various Ages in Able-Bodied Persons*
son's
Rate of 0 2 or p~
Age Velocity Consumption % 0 2 Cost Heart Rate tiviti(
(years) (m/min) (mUkg·min) Vo2max (mUkg·m) (beats/min) RER
of w~
man)
cws FWS cws FWS cws cws FWS cws FWS cws FWS rest.
6 to 12 70 88 15.3 19.6 28 0.22 0.22 114 127 0.84 0.87
13 to 19 73 99 12.9 19.1 N/A 0.18 0.20 97 117 0.76 0.82 Loa
20 to 59 80 106 12.1 18.4 32 0.15 0.19 99 124 0.81 0.92 Stu di
60 to 80 74 90 12.0 15.4 48 0.16 0.17 103 119 0.84 0.92 on t
foun
*Waters and associates23·25·26 0 2 Cl
NIA = not available
catio
were
great
ertion within the aerobic range.23 •28 in other parameters of physiologic sumption than in adults. A child's over
The fact that CWS walking requires performance such as muscle strength. lower body weight, however, results in load
less than 50% of the Vo 2 max in nor- The decline in the CWS and FWS is a higher aerobic reserve per kilogram did
mal subjects in all age groups and associated with a decrease in the of body weight than in adults. crea~
does not require anaerobic activity Vo 2 max that is independent of age.29 The plots of the energy/speed relation.
accounts for the perception that walk- The average RERs for children, tion for all age groups are relatively placi
ing requires little effort in healthy in- teenagers, adults age 20 to 59, and flat. This indicates that normal gait is of (
d ividuals. It is significant that as they adults age 60 to 80 at their self- quite efficient throughout the cus- findi
age, individuals demonstrate progres- selected FWS were 0.87, 0.82, 0.92, tomary range of walking speeds (Fig- walk
sively smaller aerobic reserves ( the and 0.92, respectively.23 These find- ure 1). muc
Vo 2max declines); this makes it more ings indicate that able-bodied adults Ralston 32 demonstrated that if the and,
difficult to compensate for the physi- customarily set their FWS just above relationship between rate of 0 2 con- quit-,
ologic penalties imposed by gait dis- the threshold where anaerobic metab- sumption and speed is determined by weig
orders that commonly accompany ag- olism is triggered. Interestingly, long a second-order equation, the equation imp,
ing. This decline in Vo 2 max has been distance runners also select an exer- relating 0 2 cost to speed yields a peci,
attributed to reduced muscle strength cise rate slightly above the anaerobic curve that is concave upward with a lirnl:
[
in older persons, which requires the threshold. 2 mmunum value at 1.33 mis
recruitment of a greater proportion of com
(80 m/min). This is approximately the
available motor units with a higher Relationship Between Rate average speed of unobserved adult
add<
percentage of fast-twitch fibers for a of 0 2 Consumption and 21 sele<
pedestrians, l.30 m/s (78 m/min).
given walking speed. 28 mall
Walking Speed T his close relationship between the
peri
In normal walking, the rate of 0 2 con- most economical walking speed and
Energy Expenditure at the the normal self-selected walking
weif
sumption depends on walking ther
Customary Fast Walking speed has been confirmed by numer-
speed. 22 •30-36 The plot of this energy/ The
Speed speed relation is approximately linear ous investigators. 28 ' 38•39
pun
When children, teenagers, and adults within the customary range of fast
age 20 to 59 years are asked to walk at walking speeds, below 1.67 m/s (100
Range of Average Walki ng
weii
a customary (self-selected) fast walk- m/min) 23 •37 (Figure 1). Above that Distances spe<
ing speed (FWS), the average rate of point, 0 2 consumption increases Fw1ctional ambulation involves tra- WOl
0 2 uptake is approximately the same, faster than does speed. Within this versing a certain distance to perform mar
averaging 19.6, 19.1, and 18.4 mL/ customary range of walking speeds, a specific activity. Average walking abl~
kg·min, respectively23' 25 •26 (Table 2). higher-order regressions do not im- distances for various activities of daily 1
The value for adults age 60 to 80 years prove d ata fit in comparison to a lin- living were measured in a variety of can
is significantly lower, however (15.4 ea1·. 23 areas in Los Angeles, California.40 The bee:
mL/kg·min), and there is a corre- Children walk less efficiently than authors found that in an urban envi- con
sponding dec]jne in the average FSW. do adults. Their BMR is higher and ronment and with an automobile helc
The decrease in the rate of energy ex- their cadence is faster to compensate available, and given a normal walking wal
penditure in older subjects is similar for a shorter stride length, resulting in speed of 1.33 m/s (80 m/min), most obe
in magnitude to the decline observed a higher rate and cost of 0 2 con- activities of dai ly Jjving require less LU

than 5 minutes of walking. As a per-

son's walidng speed declines with age
25
or pathology, however, the same ac-
tivities can require 10 to 15 minutes
c
.E
of walking, which may be difficult for 20
0)
.:,(;
many individuals to sustain without a :::i
rest. .sc 15
0
Loading li 10
E
Studies in which weights were placed ::i
<I)
c
on the body in various locations 0
5
(.)
fow1d that the increase in the rate of
0 2 consumption depended on the lo- 0"'
cation of the loads. 18•11- 43 Loads that
30 40 50 60 70 80 90 100
were placed peripherally had a much
greater effect tha11 did loads placed Walking Speed (m/ min)
.ild's over the trunk. Placement of a 20-kg
ts in load on the trunk of a male subject
:ram did not result in a measurable in- Figure 1 Relationship between t he rate of 0 2 consumption and speed of walking for
crease in the rate of 0 2 consump- children, teenagers, and adults without disability.
relation.18 On the other hand, a 2-kg load

ively placed on each foot increased the rate with the 80 m/min walking speed ob- tions are usually vasculru·, although
1it is of 0 2 consumption by 30%. This served in women in the study cited gait performance differs significantly
cus- finding is predictable because during earlier.2 L Even at this reduced speed, between the two groups. Second, of-
:Fig- walking, forward foot acceleration is the rate of 0 2 consumption was much ten no distinction is made between
much greater than tru nk acceleration higher: 56% of the Vo 2 rnax compared amputees who use upper limb assis-
f the and, therefore, greater effort is re- with 36% in a group of normal- tive devices and those who do not.
con- quired to move the same amount of weight control subjects. This rate of Third, the adequacy of prosthetic fit
:d by weight. These findings indicate the exertion is greater than that de- and duration of experience are not
importance of minimizing weight, es- manded by fast walking in normal often specified, despite the common
1tion
pecially distally, when designing lower adults. Conversely, Foster and associ- clinical observation that patients with
ds a
limb orthoses or prostheses. ates46 found that weight loss reduces inadequately fitted prostheses, or
ith a
Despite the increased rate of 0 2 the rate of 0 2 consumption dming those who have worn a prosthesis for
m/s
consumption while walking with walking. A group of obese individuals only a short time, walk less efficiently
y the
added loads, studies show that self- displayed a greater tba11 expected re- than do more experienced patients
adult
selected speeds declined only mini- duction in 0 2 consumption following with well-fitted prostheses.
n ).21
mally.42'43 One exception was ru1 ex- a weight loss program. The average
t the Prosthesis Versus Crutches
periment in wh ich subjects held weight loss was 21 kg, or 20% of body
and Lower limb amputation with or with-
weights in their hands ru1d pumped weight, whi le the reduction in energy
!king
them while walking for 20 m inutes. 44 rate was 31 % . out prosthetic replacement imposes
.mer- energy penalties for ambulation. If
The rate of 0 2 consumption with
pumping was closer to that seen with the patient chooses walking without a
fast walking, even with no added Walking and the prosthesis, increased energy is re-
ng
weight. To maintain a normal walking Unilateral Lower quired for upper limb weight bearing
speed with the increased weight on crutches. If the patient chooses a
: tra-
Limb Amputee prosthesis, increased energy is re-
would have shifted the energy de-
form mand to levels that were not sustain- Despite the considerable body of lit- qu ired to use the remaining proxin1al
uking able. erature on the energy expenditme of muscles to substitute for lost muscle
·daily The increased load of body weight walking in persons with lower limb function distal to the amputation.
~ty of carried by obese persons has also amputations,6' 48 " 60 a direct compari- Crutch walking without a prosthe-
0 The son of the results of the different sis may be a primary or secondary
been shown to increase the rate of 0 2
env1- conswnption when walking speed is studies is difficult, for several reasons. means of transportation for unilateral
10bile held constant. 45 •46 The self-selected First, the studies do not consistently amputees when necessary if a pros-
ilking walking speed in a group of severely distinguish young run putees, whose thesis is unavailable or inadequate. A
most obese women was found to average amputations are usually trau matic, study of unilateral amputees com-
e less 1. 18 m/s (71 m/min ),47 compared from older runputees, whose amputa- pared walking with a prosthesis with

the energy/speed relation, or the m et-

100 abolic cost of walking at various TA Bl
speeds, in persons with transtibial
amputations.48 -51 The rate of 0 2 con-
80 24
sumption in transtibial amputees is
"'O Traun
Q) 20% higher than in normal subjects
Q) G] walking Speed Amp1
o. - 60 18 (m/mln) at various walking speeds.50 Studies
(I) .!:: Trans
oi E of persons with traJ1Sfemoral amputa-
~-
c -
·- E
cu
~
40 12
• 02 Consumption
(mllkg·min) tions indicate that values for the
energy/speed relation are greater in
Knee
dis,
Trans
persons with transfemoral amputa- surgi
20 6 tions than for persons with transtibial Amp1
amputations. 48 •52 Hip
0 Two studies in which patients were dis;
tested at CWS under similar condi- Trans
tions illustrate the importance of the Vas cl
Amp,
level of amputation. In the fust
Syme
study,6 energy expenditure was mea- dis;
Figure 2 Comparison of 0 2 consumption and CWS with a prosthesis in individuals w it h sured in subjects with unilateral trans-
Trans
unilateral traumatic amputations at different levels. tibial amputations, knee disarticula-
Trans
tions, and transfemoral amputations
walking without a prosthesis using in- maximal upper limb exercise. This se- follov.ring amputation secondary to
•wat1
stead a unilateral non-weight-bearing vere demand accounts for the com- trauma or vascular disease. Patients t Now
crutch-assisted (swing-through ) gait. 6 mon clinical finding that patients had worn their prostheses at least
The study revealed that all the ampu- who require a non-weight-bearing 6 months and did not use upper limb
tees, with the single exception of per- crutch-assisted gait have a restricted assistive aids (witl1 the exception of
sons with vascular tra11Sfemoral am- sphere of ambulatory activities. Be- some transfemoral amputees in the grou
putations, had a lower rate of energy cause the maximal aerobic capacity vascular group). In the second tient
expend iture, heart rate, and 0 2 cost normally declines with age, older pa- study,53 healthy individuals with hip shov
wben using a prosthesis. This differ- tients have more difficulty meeting disarticulations and transpelvic am- ankl,
ence was insignificant in the vascular the strenuous demands of crutch am- putions were tested at their CWS us- cw~
transfemoral group, which probably bulation than do younger patients. If ing a similar methodology. These sub- puta
relates to the fac t that even with a pulmonary, cardiac, or other disease jects with surgical amputations met T
prosthesis, most of these patients re- processes further restrict 0 2 delivery, the following criteria: they were jects
lied on crutches for some support, in- the patient will have even greater dif- young, healthy at the time of testing, ineff
creasing the energy demand and heart had not received radiation or chemo- caus
ficulty meeting the energy demand.
rate. Traugh and associates 6 1 also therapy for at least 6 months before amp
It may be concluded that a well-
compared energy expenditure with
fitted prosthesis that results in a satis- testing, had no evidence of tumor recw~
and without a prosthesis in middle- currence, had worn their prosthesis cons
factoi·y gait not requiring crutches
aged and elderly patients with trans- for at least 6 months, and did not use exce,
significantly reduces the physiologic
femora1 amputations and reported crutches. The 0 2 cost increased at Clea
energy demand. Because crutch walk-
the same findings . each higher amputation level, from the!
ing requires more exertion than walk-
A study of a group of young pa- the transtibial to the transpelvic level tion:
ing with a prosthesis, patients with
tients (mean age, 32 yea.rs) with re- (Figure 2). Patients with higher level loco
transtibial or t ra.nsfemoral amputa-
cent lower limb fractures confirmed amputations had a less efficient gait fore,
tions should not be required to at-
the extreme cardiovascular demand of and higher 0 2 cost than those with the<
tempt to crutch walk without a pros-
crutch walking using a unilateral lower level amputations. c
thesis before the infriation of
non-weight-bearing gait. 62 After The average rate of 0 2 consump- tees
5 min of crutch walking, the rate of prosthetic prescription and training. high
tion at CWS did not depend on am-
0 2 consumption increased 32%, the putation level and was approximately mete
heart rate increased 53% (to 153 Prosthetic the same as the value for able-bodied resu
beats/min), and the RER was 1.05, in- subjects {Table 3) . The CWS, how· spee
dicating significant anaerobic metab-
Ambulation ever, did depend on the level of am- sum
olism. After 10 minutes of ambula- Level of Amputation putation, decreasing with each higher amp
tion, each parameter worsened Several investigators have used linear amputation level in both the trau· the
further, approaching peak values for or second-order equations to describe matic and surgical an1putation dem

:t- witb energy rate, b ut factoring in age

TABLE 3 Energy Expenditure in Unilateral Amputees Walking With a Prosthesis djd not improve the prediction be-
us
ial Rate of 0 2 yond the effects of baseline Vo 2 max-
n- Velocity Consumption % 0 2 Cost Heart Rate Torburn and associates 59 con-
(m/min) (mUkg·min) V02max (mUkg·m) (beats/min) RER firmed the significance of physical
is
Traumatic fitness in maintaining a CWS de-
:ts Amputees*
ies spite an increased rate of 0 2 con-
Transtibial 71 12.4 35 0.16 106 0.83
ta- sumption. Subjects with traumatic
Knee 61 13.4 0.20 109
he disarticulation transtibial amputations had a normal
111 Transfemoral 52 10.3 37 0.20 111 0.90 CWS of 1.37 mis (82 m/min) with an
ta- surgical elevated rate of 0 2 consumption of
,ial Amputeest 17.7 mL/kg·min. Their heart rate was
Hip 47 11.1 0.24 99 only slightly increased
ere disarticulation ( 113 beats/ min), and the RER was
Transpelvic 40 11.5 0.29 97 0.86, indicating that anaerobic me-
di-
the vascular tabolism was not required. Physical
Amputees*
ll'St fitness is also critical to maximizing
Syme ankle 54 9.2 43 0.1 7 108 0.85
ea- disarticulation the walking ability of persons with
ns- Transtibial 45 9.4 42 0.20 105 0.82 transfemoral amputations. Gitter and
tla- Transfemoral 36 10.8 63 0.28 126 0.96 associates63 studied a group of young,
)ns physically fit individuals with unilat-
to •waters and associates6 eral traumatic transfernoral amputa-
:nts t Nowroozi and associates53 tions. They were found to walk at
!ast a CWS of 1.2 m/s (72 m/min) with
mb a rate of 0 2 consumption of
of 13. 7 mL/kg·min, considerably faster
the groups. Interestingly, a study of pa- sumption in amputees at their CWS,
than reported in other studies of
)nd tients with vascular amputations which was slower than normal, was
transfemoraJ amputees that included
hip showed that individuals with Syme approximately the same as for normal
older, less physically fit subjects.
ankle disarticulations had a faster subjects. 49,56,57,60
l.ffi- Other studies have shown that aerobic
us- CWS than those with transtibial am- In contrast, other investigators
conditioning exercises both increase
;ub- putations.54 have found that some individuals, es-
walking speed (by 8%) and decrease
met T hese findings indicate that sub- pecially young persons with traumatic
rate of 0 2 consumption (by 6%
\l'ere jects with amputations adapt to the transtibial amputations, are able to
to 10%) in subjects with transtibial
inefficient gait (higher 0 2 cost) tolerate the increased rate of 0 2 con-
ing, and transfemoral amputations. 64 ,65
mo- caused by progressively higher level sumption required to maintain a
Achieving and maintaining both
fore amputations by selecting a slower walking speed that is close to normal.
cardiovascular fitness and muscle
: re- CWS at wh ich the mean rate of 0 2 In a study that included subjects with
strength, therefore, are critical to the
1esis consmnption does not significantly only nonvascular transtibial amputa-
economy of walking and the long-
. use exceed the normal rate (Figure 1). tions, but with a wide range in age (22
term functional status of individuals
:l at Clearly, as more joints and muscles of to 75 years), walking speed was found
with lower limb amputations.
'r om the leg are lost at higher level amputa- to be 10% lower and rate of 0 2 con-
level tions, the greater the loss of normal sumption was 20% higher than in the Traumatic Versus Vascular
level locomotor mechanisms and, there- younger (nonamputee) control sub-
fore, the greater the energy cost and jects.58 Baseline 0 2 consumption dur- Amputees
gait
with the disability. 55 ing quiet standing was found to be a The data in Table 2, which describe
Other studies of lower limb ampu- strong predictor of the rate of 0 2 the energy expenditure in able-bodied
LIIlp- tees walking at CWS also have shown consumption during walking. Sub- persons, also can be used to compare
am- higher than normal energy cost per jects with higher quiet standing 0 2 energy expenditure in younger per-
ately meter, but whether the increased cost consumpti.on had higher rates of 0 2 sons with traumatic amputations to
>died resulted from the slower walking consumption during walking, indicat- that of older individuals with vascular
flow- speed or the higher rate of 0 2 con- ing that a higher fitness level allowed amputations at the transtibial level.
. am- sumption depended on the level of the subjects to accept the higher 0 2 As shown in Table 3, the CWS and
igher amp utation and the physical fitness of demand created by the amputation rate of 0 2 consumption have been
trau- the subjects. 49·56-60 Several studies and maintain a more normal walking found to be significantly higher in
ation demonstrated that the rate of 0 2 con- speed. Age also correlated negatively subjects with traumatic transtibial

viduals with traumatic amputations betw

an d those with vascular amputations resid
is reflected in the rate of 0 2 consump- foun
tion. Huang and associates67 studied (r ==
24 treadmill ambulation at several speed Ieng·
and grade combinations. They docu- CW!
"Cl
Q) mented an average increase in rate of tran
~ -
(/) .!:
60 18 ti :s t:I Walking Speed 0 2 consumption of 123% and 164%, of 2:
~
0)-E 0
(.)"'~
respectively, in individuals with trau- with
.!::: E E • 02 ConsumpUon matic and vascular transtibial amputa- fron
~ - 40 12 O ~
tions, compared with an able-bodied cant
~ control group. Oxygen pulse, reflect- rate
ing exercise efficiency level, was lower la tee
20 6
than normal in the vascular amputees ticu.
but not in the traumatic amputees. ing
0 The RER was 0.90 for the vascular cm'
group, indicating anaerobic metabo- tot
lism was required, whereas the RERs amE
for the oth er two groups were in the tion
aerobic range (0.83 and 0.81 for the }
traumatic and able-bodied groups, re- am1
Figure 3 Comparison of 0 2 consumpt ion and CWS in individuals with traumatic versus spectively). This study demonstrated sidl
vascular amputations at different levels. tore
the mechanical penalty of transtibial
amputation, as seen in the traumatic due
amputations than in those with vas- relative ease in the young, physically group, and the additional impact of add
cular transtibial amputations. This fit individual, but it represents a age and disease in those with vascular tor
finding has been confirmed consis- much greater challenge for the older amputations. Jeni
tently in other studies.58" 60•66 •67 It is patient with a vascular amputation, in Most older patients who have mo
transfemoral amputations from vas- ual
probable that the higher exercise ca- whom aerobic capacity and muscle
cular disease are not successful long- tha
pacity of a younger person with a strength are likely to be reduced.
term prosthetic ambulators. Only a to
traumatic amputation allows a higher Czerniecki and Gitter7 1 studied a
small percentage of these patients are wit
CWS than in an older person with a group of young, fit men with unilat-
functional ambulators. 6'72 Most who
vascular amputation. The higher 0 2 eral transtibial amputations who were
are able to walk have a very slow gait Pn
cost seen in individuals with vascular fitted with prostheses. They found
velocity and, if crutch assistance is re- Rec
amputations than in those with trau- that the hip extensor muscles of the
quired, an elevated heart rate.6•60 In des
matic amputations at the same level residual limb during stance phase and
contrast, persons with traumatic par
reflects the increased disability associ- the hip flexor muscles of the residual sor
transfemoral amputations have an ad-
ated with age, deconditioning, and limb during swing phase as well as the
equate gait. 6' 63 •73'74 It may be con- fen
disease (Figure 3). The fact that the hip and knee muscles on the con- pre
cluded that every effort must be made
CWS, rate of 0 2 consumption, and tralateral lin1b demonstrated in- spe
to protect dysvascular limbs early, so
energy cost in persons with traumatic creased mechanical work during run- that transfemoral amputation does op,
transtibial amputations were very ning compared with the same muscles not become necessary. If amputation int
sinular to those in patients with ankle in able-bodied control subjects. Pow- is required, every effort should be tut
joint fusion relates to the fact that ers and associates 70 studied a group of made to amputate below the knee. Sta
both groups have a similar biome- individuals with vascular transtibial tia
chanical penalty (loss of ankle joint amputations and fo1md that hip ex- Residual Limb Length ce1
mobility) without the concomitant tensor strength on the amputated side Gonzalez and associates 56 evaluated en,
effects of advanced age or disease. 68 was the strongest predictor of both patients with transtibial amputations ies
Increased activity of the hip and CWS and FWS. These results further with residual limbs ranging from 14 to ve1
knee musculature can compensate for emphasize the importance of muscle 19 cm in length. All patients wore a pa- (S,
the restriction of ankle joint mobility strength to optimizing gait after an tellar tendon- bearing prosthesis ex- wi
and the additional loss of power from amputation. cept for one, who had a conventional sp
the ankle plantar flexor muscles in in- When walking speed is controlled hard socket with a thigh corset. No sig- SU
dividuals with transtibial ampu- during treadmill ambulation, the dif- nificant differences were noted in tic
tations.69.71 This demand is met with ference in performance between indi- walking speed or energy expenditure ate

:ms between patients with short and long several velocities and grades in trans- with and without transtibial amputa-
ons resid ual limbs. Gailey and associates 58 tibial amputees who wore three differ- tions. They found that children with
np- found a weak negative correlation ent types of prosthetic feet: a multiple- an amputation walked at a speed sim-
lied (r == - 0.32) between residual limb axis foot, a single-axis foot (sagittal ilar to that of their able-bodied coun-
eed length and rate of 0 2 consumption at only), and a SACH foot. They found terparts, but at a higher level of en-
,cu- cWS in a group of 39 subjects with the prosthetic foot type had no impact ergy consumption. The level of
e of transtibial amputations. An evaluation on the rate of energy consumption, energy expenditure was well below
4%, of 27 vascular and traumatic amputees but they did find elevated energy con- the anaerobic threshold in both
·au- with residual limb lengths ranging sumption in the transtibial amputees groups. This indicates that maintain-
llta- from 9 to 24 cm revealed no sig111ifi- compared with able-bodied control ing a normal walking speed did not
iied cant differences in walking velocity, subjects. This finding indicates that require a strenuous effort on the part
ect- rate of 0 2 consumption, or 0 2 cost re- the lack of active muscle at the ankle of the children with transtibial ampu-
,wer lated to residual limb length.75 Of par- has a greater impact on the energy cost tations.
.tees ticular clinical importance is the find- than the presence or absence of ankle
ing that a residual limb as short as 9 Bilateral Amputees
tees. joint mobility. Other studies have
ular cm will result in performance superior shown that the addition of weight (0.4 Few energy expenditure studies have
1bo- to that reported for individuals with to 1.5 kg) to the prosthesis does not in- been performed on subjects with
ERs amputations at the knee disarticula- crease the energy cost of walking for bilateral lower limb amputa-
. the tion and transfemoral levels . tions.8·49•75•86 The data, as summa-
subjects with transtibial amputations
· the Among subjects with transfemoral as long as the added mass is not con- rized in Table 4, must be interpreted
;, reamputations, James 76 found that re- centrated at the distal end of the pros- cautiously because relatively few sub-
ated sidual limb length had little effect on thesis. 58,79,so jects have been studied. This limited
ibial torque about the hip, except for ad- In an attempt to improve the gait information indicates that the bilat-
:rntic duction. He attributed the effect on of the individual with a traosfemoral eral lower limb amputee expends
:t of adduction to the fact that the adduc- amputation, a new socket, the Con- greater effort than does the unilateral
:ular tor muscles insert onto the entire amputee (Figure 4). As with unilateral
toured Adducted Trochanteric-
length of the femur and are therefore Controlled Alignment Method (CAT-
amputees, level of amputation affects
have most affected by differences in resid- performance: vascular patients with
CAM) socket, was designed to hold
vas- ual limb length. Studies are lacking Syme disarticulations walked faster
the femur in adduction and improve
ong- that relate speed and energy expended and had a lower 0 2 cost than did vas-
the grip on the pelvis. This socket has
1ly a to residual limb length in persons cular patients with transtibial amputa-
been demonstrated to improve walk-
s are with transfemoral amputations. tions, and persons with traumatic
ing speed by 10%, 0 2 cost by 21%,
who transtibial amputations performed
Prosthesis Type and rate of 0 2 consumption by 20%
r gait more efficiently than did persons with
over that required with the traditional tra.nsfemoral amputations.
is re- Recent improvements in prosthetic
quadrilateral-shaped socket.81•82 The distinction between trauma.tic
60 In design have resulted in a greatly ex-
Another modification to prostheses and vascular amputations has an even
ma tic panded choice of prostheses for per-
for transfemoral amputees is the addi- greater functional significance in bi-
n ad- sons with both transtibial and trans-
tion of a microprocessor-controlled lateral amputees, as is shown in Table
con- femoral amputations. For example,
knee extension damper. This device 4. Persons with traumatic transtibial
made prostheses with the dynamic elastic re-
sponse foot (DERF) have been devel- detects the swinging speed of the pros- amputations walked faster and at a
ly, so
oped for the transtibial amputee. The thetic shank and adj usts the rate of lower energy cost than did their coun-
does
intent of this design is to store and re- knee extension of the pneumatic knee terparts with vascular transtibial am-
:ation
turn mechanical energy during the joint to match the subject's walking putations. Subjects with traumatic
Id be
stance phase of walking, thereby par- speed. Studies have demonstrated that amputations were able to tolerate a
ee.
tially replacing the function of the tri- this "intelligent" knee prosthesis pro- higher rate of 0 2 consumption at a
ceps surae and reducing the metabolic vides a more mechanically efficient similar heart rate. Subjects with trau-
energy requirement. Energy cost stud- gait over a greater range of speeds. En- matic transfemoral amputations had
luated
ations ies comparing the DERF with the con- ergy cost was reduced between 5% and both higher rates of 0 2 consumption
ventional solid ankle- cushion heel 10%, particularly at walking speeds and reduced velocity. No subjects with
t 14to
ea pa- (SACH) foot have been equivocal, faster than CWS.83' 84 bilateral vascular amputations at the
is ex- with modest improvements in walking transfemoral level were able to ambu-
Children With Lower Limb late long enough to complete the test-
1tional speed and energy cost seen in younger
fo sig- subjects with traumatic amputa- Amputations ing protocol. This is not surprising
ed in tions. 59•66·69•77•78 Huang and associ- Herbert and associates85 compared given that individuals with unilateral
.diture ates67 tested treadmill ambulation at the energy consumption of children vascular traosfemoral amputations

kg·min) . At the slowest imposed termi

TABLE 4 Energy Expenditure in Bilaterall A mputees Wa lking With Prostheses* speed of walking (0.3 m/s, or 18 abilit:
Rate of 0 2 m/min), the rate of 0 2 consumption form,
Velocity Consumption 0 2 Cost Heart Rate of the subjects with amputations was direc1
(m/min) (mUkg·min) (mUkg·m) (beats/min) 11.1 mL/kg·min, approximately the gait ,
Traumatic same as that of the able-bodied sub-
Amputeest sumf
jects at CWS. The level of physical fit- fort c
Transtibia l 67 13.6 0.20 112
ness of the individuals with bilateral Tr
Transfemoral 54 17.6 0.33 104
amputations allowed them to tolerate vices
Vascular
Amputeest the higher rate of energy consump- weigl
Syme a nkle 62 12.8 0.21 99 tion to maintain the moderately re- per L
disarticulation duced self-selected velocity. vatec
Transtibia l 40 11.6 0.3 1 113 Gonzalez and associates 56 pointed hear1
Amputees wea ring 46 9.9 0.22 86 out that considering approximately
per I
Stubby Prostheses:!= 24% to 35% of patients with amputa-
devic
tions from diabetes mellitus lose the
by r,
*Both amputations at same level remaining leg within 3 years, it is im-
tWaters and associates 75 that
*Wainapel and associates87 portant to preserve the knee joint even
not s
if the residual limb is short. This is be-
Ex:ce
cause a tmilateral transtibial amputee
who undergoes another transtibial incn
amputation would still e>..l)end 24% mus,
30
less energy than a patient with a uni- tole-r
lateral transfemoral amputation. Pa- sum
24 tients with bilateraJ vascular amputa- wall<
tions rarely achieve a functional amp
ambulation status if one amputation is cost
CJ Walking Speed at the transfemoral level. high
t-.
• 02 Consumption Use of Stubby Prostheses grar
Wainapel and associates87 measured to ,
energy expenditure in a 21-year-old A ere
20 patient with bilateral knee disarticula- crea
tions who walked on stubby prosthe- red1
ses ("stubbies") while using a walker. 1ma
0 The patient walked faster with the fitn,
stubbies and the walker, though at a fun,
slightly greater rate of 0 2 consump- im:i:
tion, than with conventional prosthe- of i
ses and crutches. Similarly, Crouse me1
Figure 4 Comparison of 0 2 consumpt ion and CWS in individua ls with unilateral versus and associates 86 studied a subject lim
bilatera l traumatic amputations at d ifferent levels. with bilateral transfemoral amputa-
pac
tions and found that 0 2 consumption
oth
use 63% of their maximal capacity with traumatic transfemoral amputa- was 23% lower when the subject used
with an RER of 0.96, indicating sig- tions at both self-selected and im- stubbies than with long-leg prosthe-
,nificant anaerobic metabolism, to posed walking speeds. Two of the sub- ses. Walking on stubbies is cosmeti- At
achieve even a reduced velocity. Am- jects walked without any assistive cally unacceptable for most patients
The
putation of the second limb imposes devices; the other three used a unilat- (except for gait training or limited
too large a penalty on this compro- eral single-point cane. The self- walking in the home), but the data
the
Ra1
mised population to permit functional selected speed of 0.82 m/s from these case studies illustrate that
ambulation. bili
(49 m/min) corresponded with the it can result in a functional gait.
Hoffman and associates 88 con- most efficient velocity (lowest 0 2 quc
firmed the high energy demands of cost). The rate of 0 2 consumption at
walking with bilateral transfemoral was 49% greater than that in an age-
Summary de1
amputations. They recorded energy and weight-matched control group Measurement of physiologic energy Th
consumption in five young subjects (15.5 compared with 10.5 ml/ expenditure provides a method to defor

sed
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sthe-
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.bject
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)Uta-
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t.ients well-trained ischemic heart disease gen uptake with age. J Appl Physiol
The authors wish to thank the staff of
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data the Pathokinesiology Laboratory at
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: that Rancho Los Amigos National Reha-
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C h a p ter 32: En er gy Expenditure of Walking 407
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Moore WS, Malone JM (eds): Lower socket: A comparison of energy cost
lersen
gex-
1mpu-
·oint
J:
mpu-
for
::Zin
ccom·
: foot
low-
1Phys
it anal·
f
:hree

Prosthetic Suspensions and
Components
Int roduction
The variety of commercially available limb, particularly during the swing vide the most secme external
components and suspension options phase of gait. Each millimeter of dis- attachment to the residual limb. 4
for lower lin1b prostheses has grown placement creates a greater pseudar- Consequently, they are the preferred
steadily i11 recent years, offering to- throsis at the socket interface, com- mode of suspension whenever feasi-
days clinician a multitude of high- promising the amputee's comfort and ble. Until skeletal attachment be-
quality alternatives. The challenge is control of the prosthesis. Weight comes a viable option, these suspen-
to keep abreast of these new develop- bearing usually reverses the displace- sions should be considered for every
ments u1 prosthetic rehabilitation to ment to some extent, as the residual amputee.
make the most appropriate choice for limb is pushed back mto the socket
each mdividual amputee. during stance phase. Suction Sockets
Fortunately, these commercial This chronic reciprocating move- The Germans are credited witJ1 the
products, numbermg ill the hun- ment of the residual limb within the first widespread application of the
dreds, can be organized conceptually socket is often referred to as piston- concept of creating a relative vacuum
into a handful of logical groupings, ing, and it must be minimized for illside the socket to achieve suspen-
based primarily on their biomechani- successful use of the prosthesis. Fis- sion.5 This technique was unhown
cal performance or engineering de- toning has many undesirable effects, in the United States w1til after World
1
sign. Once these functional groups including the generation of shear War II, but once it became part of tl1e
have been identified, key indications stresses on the skin and functional curriculum in the prosthetic training
and limitations ca~ readily be deter- elongation of the prosthesis during programs, the method was widely ac-
mined, and mappropriate choices c~ a n___ _..,.. cented ::inr1 ,innliPcl . for np,1rl v <;()
sockets because of difficulties main-

taining the skin-socket seal over the
long term.
Chapter 33: Prosthetic Suspensions and Components 411
cians. 9 Gradually, the application of

,._ sion.5 This technique was unknown
.J'
_ _ _ __ _ ucce ~£uJ......w:~£.....Lh~-CQ.~t;.h .; i:
he suspensions, expanded from the orig-
inal transtibial application to include
transfemoral and upper limb ampu-
.. '" -
metl
sock·
ner s
1~,111
s•nal
Sl ck
oute
he
ltmb
the
and
he l
Figure 6 Prosthesis using a hidden foam
cont
panel for suspension The panel 1n this
example has been incorporated into a T
thin insert fabricated from polyethyle e 1s ra
re 4 Child wearing a rubber knee foam. (Reproduced with permission from Fig~
re, which 1s one of the simplest meth Otto Bock. HealthCare.) slee
:>f creating a vacuum seal to suspend ods
socket. (Courtesy of CPO Services, the
gap between the socket and the lin b Inc,
contours. Because the foam 1s res

tent, it c,m be shimmed slight!} o
1,;reate a mild comprc:ision for1;e for
·n the use ot suspension alterna One \\ h
:.nug fit.
, based on atmospheric pressure is anat tive
To don the prosthesis the amput e
teasiblc, generally the next best Figure 5 Postenor-opemng Syme pros- ()f a not
thesis. A fenestration in the socket allows
applies the proper tluckness ot Ii b
cc is ,tttadunent ot the prosthesis mto chu
the bulbous end of the Syme d1sart1cula- sock and places the hidden panel fil r ral ,
.1king ad,antage of anatomic con- tion to pass by the narrower region c.uefully in pl,11.e. I he panel 1s then by I
·s. \!though the loc,1lized forces due IOU
above the ankle. When the "door" that held in position by pulling a thin n
·rent in ,matom1c suspension ere covers the opening is m place, 1t suspends oca inh
Ion stocking mer the limb so~k ,l d prm
higher pressures than the ~uction the prosthesis over the supramalleolar reate
gion. (Reproduced with perm,rnon from filler, unless 1t has been incorporat d som
ants, most p,1tients tolerate this into a thm polyethvlcnc foam Im r ,ar
Otto Bock. HealthCare) fill'
alter an initial period of \Haning ( Figure 6). Once the prosthesis as \\cl
tran
the prosthesis. been donned, the triction ,md co int<
sleeve over the so1.ket prm ides the sus I ro.
pension. prcssion forces stabilize the panel I
suspc nd the socket. i~ 0
1e case of many wngenital malfor Int
the
ions as well as hmdfoot amputa ma
Socket strength is significantly re wed
s, the irregular 1.ontours of the re When the irregularities of the res1d , ii tio,
duccd ,, hen it is necessa11 to cut an sus,
al limb pro, 1de an excellent opening, even with careful rt'inlorce limb are not too pronounced, i 1s sod s1d1
hod of stabilizing the socket. ment. Consequent!), , arious alterna somctJmes possible to create a he me
ttion of a fcnc!>tration is often ace th c: to fenestrations ha, e been dcvel double-wall so1.:ket "ith localized ar or Crt
n to permit the irregular shape to oped eas of flexibilit}. Tht: inner sockc 1s pJ,I( ess,
! 111to the socket wmfort,tbly. Hrm but resilient foam can be laminated with rig1d plastic except 111 I slid
1ctimes the soc:kct is split into ap molded over the positive model of the the immediate area of the under... ts, usl Sor
,imatcly equal hahcs. If possible, residual hmb to fill the undercut ar which is saturated with a tlex1 le the1 pro
fenestration should be small and cas. 1 he exteri01 surface of the foam resin Molten wax is then poured to lllSf the
·red with a 'door to se1.ure the is then sculpted b} hand to blend into fill the region that contains the fle i TH CO'\i
l 111 place. I he posterior opening the overall sh,1pe of the limb, and a ble resin. 1 he wax is allowed to ool mo lim
1c design shown in Figure 5 illus- one piece rigid socket i!i molded o,er and solid1f, and is then h d 31( Syr
es this concept. Sometimes the the entire assembh. fhc result is a sculpted to blend into the °' erall h b lw tra1
r is omitted and a strap 01 dastk small filler ot foam that bridges the contours sm1tlar to the hidden p, cl lilt do<
r,crm Jlcadcm) of Ortlwpacd,c Surgeon~ Am

method noted above. A rigid outer and doffing and makes this suspen-
socket is then laminated over the in- sion particularly suitable for people
ner socket wax model so that it chem- with v isual impairments or hand in-
ically bonds to all exposed plastic. A volvements.
small hole is drilled through the outer In addition to providing suspen-
socket in the region of the wax, which sion for transtibial prostheses, the su-
is then melted by applying local heat pracondylar wedge also adds a mea-
until it liquefies and drains out. This sure of additional mediolateral
creates a holJow area between the control. Th is is particularly advanta-
flexible inner section and the rigid geous for a relatively short transtibial
outer wall. To apply this prosthesis, amputation, and is often combined
the amputee must force the resid ual with a suprapatellar configuration
limb to expand the flexible area w1til that helps limit socket hyperexten-
the irregular areas have slipped past sion.15 Supracondylar suspension is
and the socket is fully donned. When also frequently combined with other
the flexible area returns to its normal suspensions, such as external suspen-
oam contours, the prosthesis is suspended. sion sleeves, to supplement the pri-
this
This very difficult fitting tech11ique mary suspension and/or to add me-
to a
lene is rarely used except for selected pedi- diolateral stability.
From atric patients. The relatively fleshy
limb remnants of children tolerate the Strap Suspensions
forces required to don and doff this Hundreds of methods of strapping on
type of prosthesis more readily than a prosthesis have been described in
limb
do adult residual limbs. the literature. 16 Strap suspensions are
:esil-
easy for the amputee to adjust and
y to Supracondylar Wedges therefore readily accommodate vol-
for a
One of the most common fo rms of ume fluctuations. This is an advan- Figure 7 Supracondylar w edge suspen-
anatomic suspension involves the use tage when medical treatments such as sion. Here, the supracondyl ar wedge is in-
,utee corporated into the soft liner, simplifying
of a wedge of firm material that fits dialysis result in an unstable residual
limb donning and doffing. (Courtesy of CPO
into the area above the medial femo- limb volume, or during the period Services, Inc.)
filler
ral condyle, just proximal to the ad- when postoperative edema is rapidly
then
ductor tubercle. For most amputees, a resolving. Unfortunately, even with
n ny- cuff strap (Figure 8) . An elastic billet
localized wedge in this region ,c an the addition of a waist belt, strap sus-
c and provide excellent suspension plus pensions inevitably allow significant is used to connect the thigh cuff to
,rated pistolling and may be less comfort- the waist belt.
some measure of rotational control.
liner able than atmospheric pressure meth-
This method is widely used in both
.s has transtibial and knee disarticulation ods or anatomic suspensions. Fork Strap and Waist Belt
com· prostheses. A webbing or leather strnp that looks
el and In a hard-socket design, the wedge Suprapatellar Cuff like an inverted Y can be attached to a
is often removed for dom1ing. After The suprapatellar cuff, also known as waist belt to provide another option
the residual limb is in place, the the patellar tendon-bearing (PTB) for suspension. Because the fork strap
wedge is slipped into the socket and strap, is one of the most common is typically used only in combination
:sidual suspends the prosthesis. A transtibial types of strap suspension. It is de- with metal side joints and a leather
, it is socket can also be fabricated so that signed to fit snugly against the supra- thigh lacer, this suspension is quite
ate a the proxi mal medial wall is removed patellar tendon during swing phase, rare.
:ed ar- for donning and then clipped into suspending the prosthesis over the
,cket is place for ambulation. proximal edge of the patella, and to Si/esian Belt
cept in In a soft-socket design, a molded gradually relax when the knee is A custom-made fabric or leather strap
lercuts, cushioning liner is donned first and flexed beyond 60° so that sitting is that encircles the pelvis and suspends
tlexible then the residual limb in its lineI" is comfortable. The strap that encircles a transfemoral prosthesis is often re-
ired to inserted into the hard outer socket. the thigh is primarily intended to ferred to as a Silesian belt or SiJesian
e flexi· The supracondylar wedge usually is bold the cuff in place during sitting bandage, named after the region of
to cool molded into the liner when it is fabri- and should never be fastened so tight Silesia, located in what is now Ger-
hand- cated (Figure 7). Because the wedge is that it affects the vascular supply. For many, where this concept was first de-
all limb always held precisely in place by the added security, many patients use a veloped (Figure 9). Numerous varia-
n panel liner itself, this simplifies donning cloth waist belt in combination with a tions are described in the literature.

Figure 8 The suprapatellar cuff, often Figure 10 Elastic suspension belt. (Courtesy of CPO Services, Inc.)
used along with a waist belt as shown
here, is easily adj usted to accommodate
volume changes in t he residua l limb. Figur
(Courtesy of CPO Services, Inc.) (Cow
ing shorts have become increasingly Thigh Lacer With Side Joints
popular. These elastic suspension Prior to the development of the PTB
belts are often made from wetsuit ma- socket design in the 1950s, it was con-
terial with selective reinforcement. pern
sidered impossible for the transtibial (Fig1
They fasten about the waist with a residual limb to bear all of the body's
simple Velcro closure. Because they gree
weight long term. The use of metal men
are not attached permanently to the
hinges at the knee, in combi nation tees
prosthesis, as is the case with most
with a tightly laced leather tl1igh cor- mov
SiJesian belts, the patient can remove
set, was ubiquitous. A significant per- sion
elastic suspension belts for laundering
centage of weight-bearing forces were ally
(Figure 10).
transferred to the thigh musculature, waU
Hinge Suspensions thus relieving pressure on the residual cau~
limb. offe
Prior to World Wai· II, nearly all lower
limb prostheses in the United States This remains one of tl1e prinlary leve
indications today for the use of pro,
were suspended by metal hinges that
Figure 9 Silesian belt. (Courtesy of CPO "joints and lacer" suspension-to
Services, Inc.)
attached to a leather pelvic belt or
thigh lacer. Because of the bull<, partially unload a fragile residual
limb. 18 The bracing effect of the Sui
weight, and discomfort associated
In addition to suspending the with such bracing, these suspensions metal hinges also stabilizes the knee Tab:
prosthesis, Silesian belts and related in the coronal (frontal) plane and cha1
have become increasingly rare.
variants also provide a measure of ro- provides a positive hyperextension trar.
They persist primarily because
tational stability. 17 This can be advan- stop (Figure 11). This is sometimes Sue
they offer far more mediolateral sta-
tageous when the residual limb has helpful when knee laxity is a major cau.
bility than other alternatives. This is
poor tone and the amputee is unable concern. enh
sometimes a critical consideration,
the,
to control rotation with voluntary particularly for extremely short resid-
son
muscle contractions. The standard ual limbs. They are also commonly
Hip Joint and Pelvic Belt nee
Silesian belt does not provide signifi- prescribed for satisfied previous wear-
In a prosthesis suspended by a hip
tior
cant mediolateral stability. ers. Unfortunately, even optimally fit-
joint and pelvic belt, the metal hinge
pre
In the past decade, prefabricated ting hinge suspensions allow piston-
of i
suspensors resembling modified biking during swing phase. controls coronal plane motion while

Chapter 33: Prosthetic Suspensions and Components 41 5
_____ -- ... ..... ______ _
Figure 13 Single-axis foot. Once the

plantar surface of this foot is in contact
w ith the floor, the GRF instantly moves
forward and passes through the articula-
tion until midstance, when the anterior
stop prevents further dorsiflexion motion
at the ankle. (Reproduced with permis-
sion from DAW Industries.)
prostheses. Because of its long history

as a prosthesis, this is also one of the
most thoroughly studied devices.
Figure 12 Hip joint and pelvic belt sus- Although it may seem intu itively
pension. (Courtesy of CPO Services, Inc.)
attractive to have a foot that moves in
the sagittal plane through a range sim-
Ankle-Foot ilar to that of the biologic ankle, this is
not always the most cliJ1ically effective
Figure 11 Thigh lacer with side joints.
Mechanisms approach. Providing the variable re-
(Courtesy of CPO Services, Inc.) Prosthetic ankle-foot devices can be straint offered by functioning muscles
1ts
classified into five conceptual groups in a simple mechanical fashion has
: PTB based on their biomechanical perfor- proved to be quite difficult.
5 con-
permitting free flexion and extension mance.20 Although many recent devel- Numerous scientific studies have
stibial (Figure 12). It also provides some de- opments attempt to combine the per- concluded that the primary biome-
)Ody's gree of rotational control if the abdo- formance of two or more functional chanical distinction of the single-axis
metal men is not too fleshy. Because ampu- groups and are therefore considered foot, compared with alternatives, is
1ation tees objec~ to the bulk and restricted hybrid designs, the original five classi- that it reaches foot flat most quickly.22
h cor- movement inherent in such a suspen- fications have proved to be clinically As soon as the prosthetic foot is in full
1t per- sion, a trial with alternatives is gener- useful in characterizing components contact with the ground, the net
s were ally recommended. In patients who that are currently available. ground-reaction force (GRF) vector
lature, walk with a Trendelenburg lurch be- Each functional group of compo- instantly moves forward to fall
:sidual cause of the limited femoral leverage nents shares common indications and through the ankle joint (Figure 13).
offered by a very high amputation limitations. This makes it easy to This rapid anterior movement of the
rimary level, however, gait is sometimes im- identify good candidates, rule out GRF also generates an extension mo-
1se of proved when a hip joint is provided. 19 poor candidates, and generate a func- ment at the knee, which increases pas-
)n-to tionally appropriate prescription rec- sive knee stability. This gives rise to the
esidual ommendation.21 The prosthetist must primary indication for the use of a
of the Suspension Summary then choose a specific commercial single-axis foot- to increase knee sta-
e knee Tables 1 and 2 summarize the key ankle-foot assembly from the appro- bility.
1e and characteristics of transtibial and priate functional group based on clin- Unfortunately, the ankle mecha-
:ension transfemoral suspension alternatives. ical experience. This process should nism itself adds significant mass to
1etimes Suction alternatives are preferred be- provide the highest reliability and the terminal end of the prosthesis and
major cause they minimize pistoning and performance for each individual am- requires ongoing service. Because am-
enhance control of the prosthesis, but putee's needs, with the lowest cost putees generally prefer the lightest
they are not always feasible. Cumber- and weight penalties. and most mai11tenance-free foot op-
some hinge suspensions are rarely tion, the single-axis design is now
necessary but do have linlited indica- Single-Axis Ankle-Foot generally reserved for cases in which
, a hip tions. Local experience and patient Prior to 1950, the articulated foot knee stability is a major concern. It is
11 hinge preference also influence the selection with a single-axis ankle was the only rarely applied to transtibial prosthe-
o while of specific suspensions. widely available option for lower limb ses, when the amputee presumably
American Academy of Orthopaedic Swgeons

TABLE 1 Overview of Transtibial Suspension TAE

Generic Class Examples Primary Indication Major Advantages Chief Limitations Gen
Atmospheric pressure Roll-on locking Whenever clinically Minimizes pistoning; Precise fit, consistent Atrr
liners; hypobaric feasible best proprioception; donning necessary;
sock s; augmented greatest range of works best with
vacuum systems; motion stable residua l limb
elastomeric knee volume
sleeves
Ana
Anatomic Supracondylar To increase knee Easy to don and Restricts full knee
wedge, with or stability, for short doff, even with f lexion; suspension
w ithout residua l limb or limited hand pressure is localized
suprapatellar ligamentous laxity function or vision;
extension supracondylar
wedge adds
mediolateral
stability;
suprapatellar
extension limits
knee hyperextension
Straps Cuff; cuff+ waist Residual limb Amputee-adjustable; Some pistoning;

belt; fork strap+ volume changes good auxiliary waist belt may be Stra
waist belt anticipated suspension uncomfortable; tight
cuff may impair
circulation
Hinges Thigh corset Goints Damaged knee or Maximum Heavy, bulky,

and lacer) residual limb mediolateral and awkward to don;
anterior-posterior allows significant Hin,
stability; partial pistoning
unloading of
res idual limb
Copyright John W. Michael, All rights reserved.

Cop
can voluntarily control the knee, be- development of what is now termed foot consists of an open-cell foam inne
cause the abrupt increase in the knee the solid ankle-cushion heel (SACH) rubber that readily compresses under flexe
extension moment that this mecha- foot. Compared with the single-axis load in early stance. As the heel com- r::
nism generates might prove harmful design, the SACH foot represented presses, the foot is lowered toward the the 1
to the ligaments over time. a lighter, more durable, lower cost, ground, effectively simulating plantar mot
and maintenance-free alternative. It flexion motion. As momenttun car- beer
quickly became ver y popular world- ries the body forward, the heel gradu- desii
Solid Ankle-Cushion Heel
wide and has proven to be a very ver- ally rebounds and the GRF moves an- foot
Foot satile, albeit basic, foot design. teriorly. By late stance, when the heel and
In the 1950s, research at the Univer- ln a typical SACH configuration comes off the ground, the GRF is lo- POp1
sity of California culminated in the (Figure 14), the posterior third of the cated at the tip of the rigid wooden is of

TABLE 2 Overview of Transfemoral Suspension
Generic Class Examples Primary Indication Major Advantages Chief Limitations
ent Atmospheric pressure Suction socket with Whenever clinically Minimizes pistoning; Precise f it, consistent
f; valve; rol l-on locking feasible best proprioception; donning necessary;
liner; hypobaric greatest range of works best with
sock; augmented motion stable residual limb
vacuum systems volume
Anatomic Supracondylar Knee disarticulation Good suspension; Suspension pressure

wedge for knee or congenital rotational control is localized
disarticulation malformations
>e Straps Silesian belt Residual limb Amputee-adjustable; Some pistoning;

tight variants; volume changes good auxiliary belt may be
prefabricated elastic anticipated suspension; controls uncomfortable;
suspension belts rotation donning properly
takes skill
n;
nt Hinges Pelvic joint and belt Short residual limb Maximum Heavy, bulky,
or weak hip mediolateral awkward to don;
abductors support; partial allows significant
rotational control pistoning; can be
uncomfortable w hen
sitting
Copyright John W. Michael, All rights reserved.
U foam inner keel. The flexible toe segment for patients whose physical condition that of single-axis designs and the
s under flexes and permits rollover to occur. precludes ambulating more tha11 a cost is only slightly higher, many cli-
:el com· Despite its mechanicaJ simpli.city, few steps at a time. nicians prefer to offer multiaxial feet
vard the the SACH foot results i.n very smooth when an articulated ankle is desired.
plantar motion clinically. Although it has Multiaxial Ankle-Foot Prior to the 1970s, multiaxial feet
Jm car· been displaced by more dynamic foot Multiaxial feet contain a mechanism were not particularly durable; how-
:I gradu· designs in recent decades, 23 the SACH that offers a limited range of coronal ever, subsequent improvements have
oves an· foot remains the lightest, simplest, plane inversion and eversion as well substantially increased their reliability.
the heel and lowest cost option available. It is as sagittal plane plantar flexion and Although the rubber elements that
RF is lo· popular for infants ru1d toddlers and dorsiflexion. Because the weight and limit the extremes of motion must be
wooden is often used in preparatory limbs and maintenance frequency are similar to replaced as they wear out, the added

Flexible-keel feet are well accepted

by many ampu tees, and they are TABl
sometimes used in preparatory limbs Gene
because of the smooth rollover pro-
Sing I
vided. They are also increasingly pop-
ular in pediatric prostheses, particu-
Figure 14 The SACH foot has no mecha-

larly for smaller, lighter preschool-age
children. They are not recommended
c
nism that requ ires servicing. (Courtesy of
for activities that require a fast push-
CPO Services, Inc.)
off, such as sprinting, because it takes SAC!-
Figure 15 Mult iaxial feet. (Reproduced
with permission from Otto Bock Health- a few moments for the flexible keel to
Care) stiffen enough to aid propulsion. 26
Dynamic-Response Foot E
Dynamic-response feet are character-
ized by a spring-like keel that deflects
under load, stores potential energy,
and releases it in the latter part of
Figure 16 Cross section of a flexible-keel
foot. (Courtesy of CPO Services, Inc.) stance phase 27 (Figure 17). Since their E
development in the mid 1980s,
Flexi
dynamic-response feet have grown
mobility outweighs the disadvantage steadily in clinical acceptance to the
of periodic servicing for many pa- point that they are now one of the
tients.
The classic indication for use of a
most commonly prescribed compo-
nents.
c
multiax:ial foot is to accommodate un- T his design was originally devel-
Figure 17 Dynamic-response feet. (Re- Dyn,
even surfaces encountered in the am- produced with permission from Seattle oped to address amputee complaints
putee's vocational or avocational ac- Systems, Inc.) that the solid keel of the SACH and
t1V1t1es. This device essentially single-axis feet were too stiff to permit
functions like a universal joint so that
the foot is in uniform contact with the shattered this illusion. 25 As the cross-
comfortable ambulation at more than
a moderate pace, precluding jogging c
ground even if the surface is not level section in Figure 16 illustrates, this or similar recreational activities. Ini-
(Figure 15). The compliance of this foot is composed almost entirely of tially, this innovation was embraced by
device is also believed to contribute to resilient polyurethane rubber except highly active amputees who were de-
socket comfort by absorbing some of for a small rigid section where it bolts ligh ted to be able to participate in a
the impact of walking.24 Most, but not onto the prosthesis. wider range of recreational and sport plast
all, feet of this type also provide trans- The keel in t his example is made activities. has I
verse plane motion. With increasing clinical experi- nam
from sol id rubber and exten ds be-
These components are commonly ence, however, it became clear that from
yond the metatarsal region into the
prescribed for use by surveyors, golf- most amputees preferred a dynamic- ankl,
toe area of the foot. As a result, the
ers, hikers, and others who routinely response foot, even for routine walk- greal
forefoot is very flexible and can ac-
negotiate irregular terrain. However, ing.28 Dynamic-response feet are now ener:
commodate irregularities by bending
many community ambulators prefer considered broadly applicable to en-
into pronation or supination. T he H
the added ankle mobility offered by courage the amputee to achieve a
flexible keel also facilitates rollover, foot
multiax:ial devices because they are higher activity level. Perhaps the only
and amputees find this makes walking ergy
helpful in crossing sidewalks, parking contra indication for such feet would
easier. mos·
lots, lawns, and other common irreg- be if the amputee is unable or unwill-
The plantar surface of this design desii
ular surfaces. ing to load the forefoot, in which
is reinforced with high-strength web- the
case, the forefoot spring would be
Flexible-Keel Foot bing straps analogous to the plantar Alth
nonfunctional.
fascia of the biologic foot . As the am- sho,,
For centuries, conventional wisdom Studies have demonstrated that
putee shifts weight onto the forefoot, the
held that a prosthetic foot must have dynamic-response feet vary in their
the plantar straps tighten and gradu- spor
a rigid forefoot to provide sufficient ability to store and release energy and
ally stiffen the toe to allow pushoff. stud
stability for amputee ambulation. In that those made from carbon fiber
This is similar to the well-known adva
the early 1980s, an innovative design composites are generally more effi-
developed by an American prosthetist windlass effect in the normal foot. cient than designs using lower cost
on 1,
American Academy of Orthopaedic Sutgeons

ted
TABLE 3 Overview of Prosthetic Feet and Ankles
are
1bs Generic Class Basic Function Primary Indication Major Advantages Chief Limitations
ro- Limited ambulation
Single-axis Simplicity Inexpensive and Rigid forefoot; not
:>p- or maximum durable energy-efficient
~
cu- durability required
age
:led
1sh-
1kes SACH Rapid foot flat To enhance knee Biomechanical Abrupt dorsiflexion
~
stability stability in early stop increases knee
l to stance hyperextension
> moment; increased
weight, maint-
enance, initial cost
:ter- Multiaxial Hindfoot To accommodate Reduces stresses on Increased weight,

i:l inversion/eversion; uneven surfaces skin and prosthesis maintenance, initial
ects cost
1'-' It> internal/external
:rgy, .- 1 rotation
~ I v )
t of
heir '-
80s,
1
Flexible-keel Smooth, easy To make ambulation Comfortable and Limited pushoff;

own rollover easier reliable increased cost
the
1po-
the
evel-
&rJ To increase activity Subjective sense of Increased cost
Dynamic-response Dynamic pushoff
ain ts level dynamic
and responsiveness
G~l
:rmit
than
;ging
Ini-
Copyright John W. M ichael, All rights reserved.
ed by
e de-
in a
sport plastics. 29 In the configuration that Hybrid Designs
has been shown to be the most dy- Manufacturers have recently produced
:peri- namic (Figure 18), the spring extends several designs that combine a multi-
that from the toe region proximal to the axial ankle with a dynamic-response
1mic- ankle; the longer a given spring, the foot, in an effort to offer the advan-
walk- greater is its capacity to store kinetic tages of both concepts. Growing clin-
: now energy. 30 ical acceptance suggests tl1at this hy-
o en-
However, not all patients prefer the bridization has been effective.33
eve a
foot with the greatest measured en- Mu1tiaxia1 ankles combined with
: only
ergy return. In addition, even the flexible-keel feet are also available, but
,vould
most effective dynamic-response foot these are less common.
nwill-
design still falls far short of providing
which Ankle-Foot Components
the propulsion of a normal limb. 31 Figure 18 Spring element from a
ld be
Although many investigators have Summary dynamic-response foot. In this design, the
shown that dynamic-response fee1t are Table 3 summarizes the characteristics spring extends from the toe region to t he
that calf region. (Reproduced with permission
their the most energy-efficient option for of ankle-foot components. They are from Freedom Innovations, Inc.)
;y and sports and recreational activities, few prescribed based primarily on the am-
fiber studies have demonstrated any energy putee's activity level and functional as-
e effi- advantage at normal walking speeds pirations. The prosthetist chooses the witl1in the appropriate functional clas-
r cost on level surfaces. 32 specific commercial product from sification that is believed to offer the

the addition of a friction adjustment will b

or a spring extension aid, the cadence the la
is still severely restricted. 36 collaI
Because of these dual biomechani- ampu
cal shortcomings, basic single-axis best t
knees are increasingly rare. Amputees
with sufficient strength and reflexes to Pol~
safely control such a device are also Polye
able to vary their walking speed; the r
therefore, it is rarely an optinial tain,
choice for adults. Pediatric applica- roost
tion is more common, in part because the -f:
the shorter lower leg swings at a faster linka
rate than the longer pendulum of the knee
adult prosthesis. Five-
also J
Stance-Control Knee Pc
The stance-control knee is the m ost biorn
Figure 20 Most stance-control knees use
a friction-brake mechanism fo r added commonly prescribed p rosthetic knee creas
stance stability. In the cross section de- design worldwide.37 These mecha- distil
picted here, wei ght bearing compresses nisms typically have a weight- ter <
Figure 19 Child wearing prostheses with the spring and causes the knee to clamp activated friction brake. As the ampu- outsi
single-axis knees. (Reproduced with per- against the cylindrical brake bushing. Un-
mission from Otto Bock HealthCare.) tee applies weight to the prosthesis in bar
weighting the prosthesis allows t he
spring to open the clamping mechanism early stance, the brake is engaged and insta
so t hat t he lower leg can swing free ly. the resulting friction holds the knee (ICC
greatest value, function, and durability (Reproduced with permission from Otto securely (Figure 20) . Stance-control cally
without adding excessive weight. Bock HealthCare.) knees are sometimes used in prepar a- thro
tory prostheses because their simplic- axes
most maintenance-free option . It is ity and safety help new amputees these
Prosthetic Knee still widely used in children's prosthe- learn to walk on a prosthesis.38 poin
Mechanisms ses, where rugged simplicity is a pri- To flex the knee, the amputee must tivel
mary consideration. It is also some- shift weight onto the opposite leg. It
Prosthetic knees can be grouped into
times recommended for amputees Once the prosthesis is fully unloaded, cate,
five functiona l classes based on their
who live in rem ote areas and cannot the brake mechanism is released so the
biomechanical performance. 34 This
arrange regular prosthetic follow-up. the lower leg can then swing freely. rior
initial classification suggests primary ent}
Unfortunately, the basic single-axis Most patients have no trouble learn-
indications and specific limitations ing to walk in this fashion, even cate·
knee has two major biomechanical
and provides a convenient guideline though it results in an abnormal gait stro:
deficiencies. First, the knee has no in-
for prescription. Once the appropri- pattern. put(
herent stability, and therefore must be
ate functional class has been deter- carefully controlled by the amputee The requirement to shift weight off cha1
mined, the prosthetist must then with every step to prevent collapse of the prosthesis prematurely to allow teri<
choose the specific product that he or the prosthesis. 35 Because the typical knee flexion presents few problems at tion
she believes will offer the greatest du- new amputee today is an elderly indi- slow cadences. However, if the ampu· (
rability and functional performance vidual with concomitant medical tee n-ies to walk at a more normal few
with the lowest cost and weight pen- problems, such perfect control of ev- speed, the lack of knee flexion under the
alty. ery step is often an unrealistic expec- partial weight bearing during late atee
tation. stance phase significantly disrupts the ICC
Single-Axis Knee Equally important, w ith a free- gait pattern. For this reason, stance- ante
Until World War II, the only pros- swinging knee, the lower leg is essen- control knees are most appropriate kne
thetic knee that was widely available tially a pendulum with a rate of swing for limited ambulators who are capa· cen
in the United States was a basic hinge limited by its length. As a conse- ble of walking onJy at a slow pace be- and
design that allowed the lower leg to quence, the amputee is forced to walk cause of cardiopulmonary restrictions star
bend freely du ring the swing phase of at a constant, slow speed. Attempts to or similar comorbidities. bea
gait (Figure 19). Because of its me- accelerate result in excessive knee The use of bilateral friction-brake lCC
chanical simplicity, the single-axis flexion in early swing, which slows knees may present a risk to the amp u- age
knee remains the least expensive and the cadence even further. Even with tee in t he event of a fall, because it the

nt will be impossible to voluntarily bend

ce the knees and control the direction of
collapse. Accordingly, for bilateral
li- amputees, the stance-control knee is
tis best used on only one side, if at a]\.
to Polycentric Knee
lso Polycentric knees can be identified by
~d; the multiple articulations they con-
11al tain, with foul' axis points being the
ca- most common configuration. Because
JSe the four axes aTe connected by four
:ter linkage bars, this type of polycentric
the knee is also called a four-bar knee.
Five-, six-, and seven-bar designs are
also now commercially available.>9
Polycentric designs offer several
LO St biomechanical advantages and are in-
nee creasingly popular as a result. A key
ha- distinction is that the functional cen-
;ht- ter of rotation is generally located
pu- outside the knee joint itself. In a four- Figure 21 Polycentric kn ees have an ini- Figure 22 One special class of polycentric
tial ICOR that typically falls proximal and knees is designed to minimize the protru-
s in bar type of polycentric knee, the
posterior to t he mechanical axes. As the sion beyond the end of the socket in f lex-
and instantaneous center of rotation knee is f lexed, the ICOR usually moves in ion. They are intended for use w ith knee
:nee (ICOR) can be determined geometri- an anterior and distal direction, as shown disarticulation and similar very long resid-
1trol cally by drawing straight lines here, along a characteristic arc called th e ual limbs. (Reproduced with permission
ara- through the posterior and anterior centrode. (Reproduced with permission from Otto Bock HealthCare.)
)lic- from James Breakey, PhD, CP.)
axes (Figure 21). T he point where
Ltees these lines intersect is the ICOR- the pulls the lower leg back tmder the
point in space where this knee effec- socket at 90° of flexion; this design is
nust tively articulates. 40 easier to voltmtarily control t11e pros- ideal for knee disarticulations and
leg. In a typical design, the ICOR is lo- thesis.41 similarly very long residual limbs.44
<led, cated posteriorly and proximally to Polycentric knees offer yet another In recent years, complex polycen-
d so the mechanical knee axes. The poste- biomechanical advantage-additional tric knees featuring five-, six-, or
·eely. rior position makes t his knee inher- toe clearance at midswing. The actual seven -bar linkages have become
:arn- ently stable because the GRF is lo- ground clearance can increase as available. Most offer more stance-
even cated far anteriorly, thus generating a much as 3 cm for some knee de- phase functions than four-bar de-
I gait strong extension moment. As the am- signs,42 thus significan tly reducing signs, such as a geometric lock that
putee starts to flex the knee, the ICOR the risk of tripping on environmental automatically engages and disengages
1t off changes; typically, it moves more an- obstacles. during ambulation. Some provide a
illow teriorly and distally with each addi- Because of these biomechanical limited range of controlled knee flex-
:ns at tional degree of knee flexion . advantages, polycentric knees are ion during the loading response phase
:npu- Once the knee has been flexed a widely prescribed. Many clinicians of gait, si mulating this shock-absorb-
>rmal few degrees, the ICOR fal ls in front of advocate their use over friction-brake ing motion of the biologic knee (Fig-
mder the GRF and a flexion moment is cre- stance-contrnl components when ure 23). Gait studies have confirmed
late ated. This combination of a posterior added stability is desired. Polycentric that these stance-flexion knees result
ts the ICOR at extension and a much more knees also work very well bilaterally, in a more biomechanically normal
ance- anterior ICOR after a few degrees of providing stability without preventing gait pattern.45
priate knee flexion makes the typical poly- voluntary knee flexion under partial
capa- centric knee very stable in early stance weight bearing. Manual Lock Knee
ce be- and yet relatively easy to flex in late In addition to polycentric designs Manual lock knees provide maximum
ctions stance, even under partial weight that offer enhanced stability, a second stability by locking the knee in full ex-
bearing. The proximal location of the group of polycentric knees is designed tension throughout tl1e gait cycle. Be-
-brake ICOR also gives the ampu tee a lever- to mjnimize the protrusion beyond cause swing-phase knee flex ion is
1mpu- age advantage over an articulation at the socket in flexion.43 As shown in eliminated, the prosthesis is function-
1use it the anatomic knee center, making it Figure 22, the linkage in these knees ally too long; therefore, the amputee

Because pneumatic knees use air as

the control medium, their function is
not affected by ambient temperature;
they may be preferable in bitterly cold
climates where the thickening of hy-
draulic fluid could be a concern. The
primary limitation to pnemnatic
knees is that they may not provide
sufficient resistance for very vigorous
activities because gases such as air are
compressible.52 In clinical experience,
however, they are well accepted by the
amputee and provide good swing-
phase control for many people.
Hydraulic knees, in contrast, use
an incompressible liquid to control
knee motion. For this reason, they
can provide as much swing-phase re-
sistance as necessary,53 and some are
Figure 23 Polycentric knee with more Figure 24 This hybrid knee combines the
complex linkage to provide controlled
designed to provide hydraulic stance
stability of a polycentric knee with the
knee flexion in early stance phase. (Re- cadence response of a pneumatic f luid- stability as well. Because only a small
produced with permission from Otto volume of liquid is required for Figur,
control cylinder. The individual adj ust-
Bock HealthCare.) lie kn
ment valve allows the prosthetist to inde· swing-phase control, some hydraulic
pendent ly set the amount of knee f lexion pend
knees are considerably smaller and well
and knee extension resistance. (Repro-
must hip-hike, vault, circumduct, or lighter than pneumatic models. ta nee
duced with permission from Otto Bock
HealthCare.) Fluid-controlled knees are more with
abduct the prostl1esis to clear the floor. Care)
complicated and therefore more
These necessary compensations not
amputee from bending the knee in costly than simpler mechanical de-
only result in an abnormal gait but are
the event of a fall. vices, and they require periodic ser- nent
also believed to increase the energy wel]
Locked knees are routinely pro- vicing to replace worn seals. However,
cost of ambulation. It is customary to re sis·
vided for toddlers and small children many amputees consider the increase
shorten a prosthesis with a manual swin
until they have developed sufficient in fimction well worth the additional
Jock knee approximately l cm to facil-
balance to walk with a free-swinging cost and maintenance.
itate toe clearance; however, this knee. 49 Recent studies have chal- Mic
means that the amputee will seem to lenged the assumption that this prac- Hybrid Knees The
step into a hole with each gait cycle. tice is justified, however, because even In an effort to offer the amputee a sor c
Because of the abnormal gait com- very young children fitted with a more versatile knee component, de- resis
pensations required, the manual lock polycentric or simiJar free-swinging signers have created knees that com- whil
knee can be considered the knee of knee learn to master its use and ap- bine the features of one or more of pro,
last resort and should not be used if a pear to develop a more mature gait the generic functional groups dis- stud
polycentric or other design will suf- pattern earl ier than those who transi- cussed above. One of the most clini- cont
fice. If it must be used temporarily, tion from a locked knee prosthesis. 49 cally popular combinations uses a mor
because of patient weakness or simi- polycentric knee with its biomechani- mor
lar considerations, the manual lock Fluid-Controlled Knee cal advantages and adds a hydraulic acce
knee should be replaced with a more The term fluid-controlled knee refers or pneumatic fluid-controlled unit to beer
functional mechanism as soon as fea- to a prosthetic knee that incorporates provide variable cadence swing-phase 1
sible, before the gait faults become a pnewnatic or hydrauUc unit to con- controls4 (Figure 24). in le
habitual. trol knee motion.so Research has Another hybrid knee with hydrau- to i.r
It appears that a locked knee does shown that fluid-controlled knees lic control (Figure 25) provides hy· abli
not provide a more energy-efficient provide a smoother, more normal draulic swing-phase control for vari· grea
gait than a free-swinging knee, 46 but swing-phase movement and automat- able cadence; hydraulic stance control, dail
it may permit feeble elderly patients ically compensate for moderate in the form of yielding resistance to the
to walk more rapidly47 and therefore changes in the amputee's cadence.5 1 knee flexion dming the first half of and
be preferred for this population. 48 They are therefore indicated when- stance phase; and an optional manual the~
Locked knees should rarely be used ever the amputee is capable of walk- lock, for added safety during activities cro1
bilaterally because they prevent the ing at variable speeds. such as climbing ladders. 5 s Compo- cial

1ras
,n is
Ute;
cold
hy-
The
1atic
vide
rous
rare
:nee,
rthe
ring- Figure 26 Torque absorber. A, Side view. B, The device shown can be adjusted, as shown
in t he transverse view, to increase or decrease the resistance to motion. (Reproduced
with permission from Otto Bock HealthCare.)
use
ntrol
they
e re-
e are
ta nee
small
for Figure 25 This hybrid knee has a hydrau-
lic knee control cylinder that offers irnde-
:aulic pendently adjustable swing resistance as
and well as a yielding stance-flexion resis-
tance for added stability. (Reproduced
more with permission from Otto Bock Health-
more Care)
l de-
: ser- nents that provide stance security as Figure 27 Positional rotator. A, Side view. B, Amputee uses the device to enter a vehi-
'/ever, well as variable cadence swing-phase cle. (Reproduced with permission from Otto Bock HealthCare.)
:rease resistances are often called "stance and
tional swing" units.
tasks such as standing during surgery Other Functional
Microprocessor Control or hairdressing, and recreational activ-
ities such as a bent-knee stance for
Components
The recent addition of microproces-
golfing or skiing. No discussion of lower limb pros-
1tee a sor control to automatically adjust the
thetic components would be complete
.t, de- resistance of fl uid-controlled knees
Knee Components without mentioning several items that
com- while the amputee is walking has
provide additional functional capabil-
ore of proved its clinical value.56 Scientific Summary ities in the prosthesis. These devices
s dis- studies suggest that microprocessor Table 4 summarizes the characteris- are typically located in the shin or
clini- control makes the gait kinematics
tics of the functional classes of pros- thigh region of the prosthesis.
1ses a more normal 57 and may result in a
thetic knees, allowing the clinic team
chani- more energy-efficient gait.58 Amputee Torque Absorber
to quickly rule out biomechanically
lraulic acceptance of this technology has
inappropriate alternatives and to fo- The torque absorber (Figure 26) is a
rnit to been very encouraging.59
cus on those components most suit- small component that permits con-
-phase The use of microprocessor control
in lower limb components is expected able for the individual. In many in- trolled transverse rotation 60 and
to increase steadily in future years, en- stances, hybrid designs that combine thereby absorbs many of the stresses
ydrau-
.es hy- abling the amputee to engage in a the characteristics of two or more that would normally be transmitted
r vari- greater range of normal activities of functional classes are preferred. Mi- from the floor to the prosthetic com-
ontrol, daily living. In addition to providing croprocessor control makes the knee ponents and ultimately to the ampu-
ll1Ce to the ability to adjust the stance stability component self-adjusting, and al- tee's skin. 6 1 The torque absorber may
half of and swing-phase control of the pros- though presently limited to fluid- be used in lieu of a multiaxial ankle,
11anual thesis while the person is walking, m i- controlled mechanisms, may be ap- or to supplement the movement pro-
:tivities croprocessor control can provide spe- plied to other functional classes in the vided by a multiaxial foot. For bilat-
:ompo- cialized resistances that facilitate work future. eral amputees, torque absorbers are

TABLE 4 Overview of Prosthetic Knees

Generic Class Basic Function Primary Indication Major Advantages Chief Limitations
Single axis Simplicity Single-speed Inexpensive and Fixed cadence and

(Constant friction) walking only if hip durable low stability
control is good or
better or w hen
maximum durability
is required
Stance-control Increased General debility; Improved knee Delayed swing phase;

weight-bearing poor hip control stability must unload fully to
stability flex or sit
Polycentric Positive stability and To enhance knee Stable without Increased weight,
ease of flexion for stability; special disrupting swing maintenance, initial
swing phase; special design available for phase; special design cost
design available that knee disarticulation provides cosmesis
provides sitting for long residua l
cosmesis for long limbs
Figur
residual limbs
an i
Sep a
nism
that
the
Manual lock Knee of last resort Ultimate kn ee Eliminates knee Abnormal gait; perrr
stability flexion awkward sitting
som
thes
tary
reci1
Fluid-controlled Permits cadence Able to vary walking Variable cadence; Increased initial cost;
Po~
change; speed more natural gait; may involve The
micro-processor hydraulic stance increased weight or
control offers most control adds stability maintenance
turr
normal gait pattern ima
low:
the
biliit
terii
acti
sitic
Copyright John W. M ichael, All rights reserved.
whe
twe,
corr

Shock-Absorbing Pylon 2. Michael JW: Prosthetic knee mecha-

nisms. Phys Med Rehabil: State of the
In recent years, telescoping spring-
Art Rev 1994;8:147-164.
loaded pylons have become available.
T hese components are intended to 3. Meier RH, Meeks ED, Herman RM:
Stump-socket fit of below-knee pros-
partially replace the biomechanical
theses: Comparison of three methods
shock absorption that is lost when the
of measurement. Arch Phys Med
leg is amputated. 62 Rehabil 1973;54:553-558.
Although scientific data are limit-
ed,63 clinical acceptance of these com- 4. Grevsten S, Eriksson U: Stump-socket
contact and skeletal displacement in a
ponents suggests that the amputee
suction patellar-tendon bearing pros-
perceives an increase in comfort while
thesis. JBone Joint Surg Am 1974;56:
using a shock-absorbing pylon, pas- 1692- 1696.
ticularly for activities such as de-
5. Canty TJ: Suction socket for above
scending stairs or stepping down
knee prosthesis. United States Naval
from a curb or vehicle. T hese compo-
Med Bull 1949;49:216-233.
ase; nents (Figure 28) are ro utinely rec-
to ommended for active amputees who 6. Levy SW: Skin problems of the leg
amputee. Prosthet Orthot Int 1980;4:
engage in recreational or competitive
37-44.
sport, because of the higher impacts
involved in s uch activ ities, 64 yet they 7. Kristinsson 0: The ICEROSS concept:
h ave also been well accepted by gen- A discussion of a philosophy. Prosthet
eral community ambu.lators. Orthot Int 1993;17:49-55.
8. Fillauer CE, Pritham CH, Fillauer KD:
Evolution and development of the
Conclusion Silicone Suction Socket (3S) for
ial It is rarely possible to prescribe pros- below-knee prostheses. J Prosthet
thetic components and suspensions Orthot 1989; l:92-103.
solely o n the basis of scientific evi- 9. Heim M, Wershavski M, Zwas ST, et al:
dence because of the dearth of avail- Silicone suspension of external pros-
Figure 28 Dynamic-response foot with
able objective data. It is always possi- theses: A new era in artificial limb us-
an integrated vertical shock absorber.
Separate vertical shock-absorbing mecha- ble, however, to recommend specific age. J Bone Joint Surg Br 1997;79:
nisms are also available, including units devices based on a logical rationale. 638-640.
that also provide torque absorption in One of the most w idely accepted ap- 10. Jain AS, Stewart CPU: The use of the
the transverse plane. (Reproduced with proaches is to match the biomechani- shuttle lock system for problem trans-
permission from OSSUR.) femoral suspension. Prosthet Orthot Tnt
cal performance of the prosthetic
components to the individual ampu- 1999;23:256-257.
tee's functional goals and physical 11. Goswami J, Lynn R, Street G, et al:
sometimes used in pairs in each p ros- abilities. Walking in a vacuum-assisted socket
thesis, to provide twice as much ro- To facilitate this approach, lower shifts the stump fluid balance. Prosthet
tary motion and thereby facilitate a Ortl10t Int 2003;23: l 07-113.
limb components and suspensions
reciprocal gait. can be grouped conceptually into spe- 12. Chino N, Pearson JR, Cockrell JL, et
al: Negative pressures during swing
cific classes based on their perfor-
phase in below-knee prostheses with
Positional Rotator mance characteristics. This allows in-
cost; rubber sleeve suspension. Arch Phys
appropriate choices to be quickly Med Rehabil 1975;56:22-26.
The positional rotator is a locking identified and ruled out. The clinic
tor 13. Doyle W, Goldstone J, Kramer D: The
turntable, generally located just prox- team can then focus o n selecting the Syme prosthesis revisited. J Prosthet
imal to the prosthetic knee, that al- opbma1 specific design for each indi- Orthot 1993;5:95-99.
lows the amputee to passively rotate vidual amputee, based on the best 14. Meyer LC, Bailey HI, Friddle D: An
the lower leg (Figure 27). This capa- currently available scientific evidence improved prosthesis for fitting the
bility facilitates sitting, dressing, en- and local clinical experience. ankle-disarticulation amputee. JCIB
tering a vehicle, and similar everyday 1970;9: ll-15.
activities. As a general guideline, a po- References 15. Breakey JW: Criteria for use of supra-
sitio nal rotator should be considered l. Sta.ros A, Rubi n G: Prescription con- condyla.r and supracondylar-
whenever there is sufficient space be- siderations in modern above-knee suprapatellar suspension for below-
tween the knee and the socket for this prosthetics. Phys Med Rehabil Clin N knee prostheses. Orthot Prosthet 1973;
component. Am 1991;2:311-324. 27:14-18.

'
I
Chapter 33: Prosthetic Suspensions and Components 427 i
;y 59. Datta D, Howitt J: Conventional ver- the lower extremity in locomotion. 64. Hsu MJ, Nielsen DH, Yack J, et al:
in sus m icrochip controlled pneumatic J Bone Joint Surg Am 1948;30:859-872. Physio logical comparisons of physi- I
swing phase control for trans-femo ral 62. Miller LA, Childress DE: Analysis of a cally active persons with transtibial
cnee amputees: User's verdict. Prosthet vertical compliance prosthetic foot. amputation using static and dynamic
Orthot Int 1998;22: 129- 135. J Rehabil Res Dev 1997;34:52-57. prostheses versus persons with non-
60. Racette W, Breakey JW: Clinical expe- 63. Hsu MJ, Nielsen DH, Yack HJ, et al : pathological gait during multiple-
rience and functional considerations Physiological measurement of walking speed walking. J Prosthet Orthot
ffi- of axial rotators for the amputee. and running in people with transt ibial 2000; 12:60-67.
ith Orthot Prosthet 1977;31:29-33. amputations with 3 different prosthe-
free- 61. Levens AS, Inman VT, Blosser JA: ses. J Orthop Sports Phys Ther 1999;29:
I
ic Transverse rotation of the segments of 526-533.
I:
I
1,
Tran-
sthe-
et
of
pros-
l0-65.
. fluid
II
;h
L
or
.djust-
1et Res
) S:
nical
·e-
it.
Lila- I
ee
,-292.
ry D:
se
:s. Arch
82.
1tistik
1tion of
:h
al:
: knee
I
A
ure by
L1tee
and
~tic
20:

I
Amputations and Disarticulations
Within the Foot: Surgical
Management
John H. Bowker, MD
Introduction
Any surgeon who deals with disorders amputation surgery techniques, the transtibial or transfemoral amputa-
of the foot and ankle will likely face surgeon now has the opportunity to tion, which requires a prosthesis for
the need to perform an amputation of consider the foot rather than the tibia weight bearing. In addition, partial
part or all of a foot, most frequently or femur as the level of choice for am- foot amputations and disarticulations
in emergency situations as a result of putation in selected cases of trauma, result in the least alteration of body
infection, ischemia, or trauma. This ischemia, or infection with or without image of any lower limb ablations, of-
area of surgical care fortunately has diabetes mellitus. 1 ten requiring only shoe modifications
become a much more common part Partial foot ablation offers several or a limited oriliosis or prosiliesis.
of the surgeon's repertoire in recent important advantages over amputa-
years as a result of a wider appreciation at more proximal levels. With at
tion of the functional benefits that re- least the hindfoot remaining, tl1e par- Causal Conditions
tention of a portion of the foot offers tial foot amputee can continue to
Infection
many patients. Of equal importance, bear weight directly on the residual
advances in material science have refoot in a manner t hat approximates The most common cause of partial
sulted in improvement of partial foot normal with regard to proprioceptive foot ablations today is infection with
prostheses, foot orthoses, and shoe feedback. This is in sharp contrast to necrosis in diabetic patients. A nor-
wear. the transtibial amputee, who must in- mal bony prominence, combined
Until the latter half of the 20th terpret an entirely new feedback sys- with sensory neuropathy and inap-
century, partial foot amputations and tem. The degree to which normal propriate shoe wear, often produces
disarticulations were performed al- walking function can be prosthetically an ulcer that penetrates the full thick-
most exclusively for trauma. "When or orthotically restored is relative to ness of ilie skin into the bones and
dry gangrene occurred as a result of the loss of forefoot lever length and joints beneath, with deep infection
critical limb ischemia or wet gangrene associated muscles. This ranges from ensuing.
occurred as a result of infection, the virtually normal gait, in the case of
accepted treatment was a major lower single lateral ray (toe and metatarsal) lschemia
limb amputation. Because the ratio- amputation, to significantly impaired
Ischemia of the foot may result from
nale was to amputate at a level at gait in the case of midtarsal (Cho-
a variety of conditions, including pe-
which primary healing could safely be part) disarticulation. Barefoot walk-
ing is significantly impaired in most ripheral vascular disease with or with-
a11ticipated, most often the transfem-
cases because of the loss of plantar out diabetes mellitus, showers of mi-
oral level was chosen. Failure of pri-
mary healing posed a very real danger foot smface, and full restoration of croemboli after cardiac surgery,
of death in the preantibiotic era, more complex activities such as run- arteritis associated with lupus erythe-
when the emphasis was on survival ning may be problematic. In elderly matosus and other collagen diseases,
rather than functional rehabilitation. patients, however, retention of even vasoconstriction following treatment
Today, however, with convergent ad- the hindfoot can preserve far greater of hypotension, cryoglobulinemia,
vances in wound healing, tissue oxy- independence in both transfer activi- and frostbite. Smoking can be an ag-
genation, and antibiotic therapy, as ties and household ambulation with- gravating factor in all these condi-
well as improvements in vascular and out a prosthesis than will either a tions.

tritic
bum
shou
do
evalt
Tisst
majc
it ca
vasc1
with
then
Pre
Figure 1 Adult with healed lawnmower
amputation of the first, second, and third Oxyi
toes. The fourth and fifth toes are sen- prof
sate and do not project distally, providing way~
a contour compatible with easy shoe fit- sive
ting. (Reproduced with permission from
tion
Bowker JH, San Giovanni TP: Amputa- Figure 2 Bilateral Chopart disarticulations fo llowing frostbite closed with split-thickness
tions and disarticulations, in Myerson MS skin grafts. The large ulceration at t he distal end of t he left residua l foot resulted from surg
(ed): Foot and Ankle Disorders. Philadel- shear forces from a flexible ankle-foot orthosis w it h distal fi ller. (Reproduced with per- peda
phia, PA, WB Saunders, 2000.) mission from Bowker JH, San Giovanni TP: Amputations and disarticulations, in Myerson does
MS (ed): Foot and Ankle Disorders. Philadelphia, PA, WB Saunders, 2000.) foot
SUPJ
often present with crude amputa- pres:
Dop
tions. Less common are thermal inju-
wid~
ries, which include frostbite and
they
burns (Figures 2 and 3). Burns are
foot
most often associated with diabetic
tien1
sensory neuropathy or electrical in-
sure
jury.
cifie.
vessc
Level Selection shur
quat
The indications aJ1d contraindica-
priv:
tions to amputations and disarticula-
suffi
tions within the foot include several
cord
critical factors. Some are not control- thes,
lable and/or reversible by the efforts sual
of the surgeon, but others are. One to .a
uncontrollable element is that ampu· toes.
tation must be done proximal to a IJ
malignant tumor, an irreparably dam· indi
aged body part, or gangrenous tissue. sion
The bony level selected must match sure
Figure 3 A, Autoamputation of right toes from frostbite. B, Radiograph showing spon- the skin available in terms of length eval
taneous synostosis of al I five metatarsal heads. (Reproduced with permission from and quality, to ensure closure without
Bowker JH, San Giovanni TP: Amputations and disarticulations, in Myerson MS (ed): Foot
Alth
tension and placement of scar away not
and Ankle Disorders. Philadelphia, PA, WB Saunders, 2000.)
from areas of d irect weight-bearing mea
trauma. A lack of skin in relation to fusic
Trauma motor vehicles (Figure 1). They in- bone, therefore, requires ablation to a pro>
clude crush injuries with or without level at which these criteria can be dors
The most common traumas leading fractures, degloving injuries that ex- met2 (Figme 4). Other factors are at usef
to partial foot ablations are those re- pose a significant portion of the skel- least partially controllable and/or re· sma
sulting from accidents with moving etal structure, or lacerations that de- versible, such as nicotine addiction, benc
machinery, such as lawnmowers or vitalize the forefoot. These patients poor serum glucose control, and nu· oxy~

Chapter 34: Amputations and Disarticulations Within the Foot: Surgical Management 431
tritional deficiencies (low serum al-

bUJ1lin). Altl1ough these factors
should not dictate level selection, they
do deserve adequate preoperative
evaluation and assiduous correction.
Tissue oxygen perfusion is often a
major determinant of level; however,
it can sometimes be improved by the
vascular surgeon or compensated for
with postoperative hyperbaric oxygen
therapy.
Preoperative Assessment
Oxygen perfusion of tissues at the
proposed level of amputation is al- Figure 4 Left foot of a 17-year-old man who sustained partial forefoot amputation at
ways crucial to healing, so a noninva- age 9 years in a motorcycle accident. An attempt to salvage the residual forefoot with
sive evaluation of the arterial circula- split-thickness skin grafts resulted in a stiff, painf ul foot with frequent ulcerations. A
tion must be made before definitive revision to a Syme ankle disarticulation was performed. A, Preoperative lateral view.
ness 8, Plantar view. (Reproduced with permission from Bowker JH, San Giovanni TP: Ampu-
surgical care is initiated. Although
rom tations and disarticulations, in Myerson MS (ed): Foot and Ankle Disorders. Philadelphia,
per- pedal pulses may be palpable, this PA, WB Saunders, 2000.)
rson does not always mean that distal fore-
foot and digital flow are adequate to
support healing. Forefoot and toe to 40 mm Hg indicate that the wound predicting the healing of ischemic ul-
pressures may be obtained using should heal without the assistance of cerations and amputations in the
uta- hyperbaric oxygen.5 A value less than forefoot of 59 patients, 22 with diabe-
Doppler devices. Although these are
nju- 20 mm Hg at a given location indi- tes mellitus and 37 who did not have
widely available and very portable,
and cates that healing is unlikely to occur diabetes. The outcome was correctly
they are of limited use in determining
are at that level. 6 The predictive value of predicted in 95% of the patients by
foot amputation levels in diabetic pa-
>etic this test can be significantly enhanced tcPo 2 , in 87% by LDV, but in only
tients because of artificially high pres-
in- by an oxygen challenge, administra- 52% by ankle systolic pressures. If
sure values obtained from heavily cal-
cified and hence incompressible tion of 100% normobaric oxygen via such studies indicate that perfusion
vessels. In addition, arteriovenous a snug mask for 20 minutes. 7•8 Shef- will not support healing, a vascular
shunting in the foot may give ade- field9 found that an increase of TcPo 2 surgery consultation should be ob-
quate pressures at the ankle while de- to 40 mm Hg or more indicated suffi- tained to see if vessel reconstruction
iica- cient tissue perfusion for hyperbaric or recanalization will allow limited
priving the distal forefoot and toes of
:ula- sufficient oxygen. 3 Pulse volume re- oxygen therapy to be of practical ben- amputation at the time of revascular-
veraJ cordings, in contrast, can overcome efit.9 Harward and associates 10 found ization. However, no currently avail-
trol- these deficiencies by providing a vi- that an increase of 10 mm Hg over a able test, invasive or noninvasive, pre-
forts sual waveform image of pulsatile flow baseline value is predictive of wound dicts failure of healing with total
One to all lin1b segments, including the healing. If vascular intervention is not accuracy. Accordingly, these evalua-
npu- toes. 4 feasible and amputation remains as tions remain only guides in the total
to a If pulsatile flow is not detectable, the only option, TcPo2 measurements assessment of the patient.
:iam- indirect determination of skin perfu- may be repeated in the hyperbaric
ssue. sion by transcutaneous oxygen mea- chamber with 100% oxygen at
1atch surements (TcPo2 ) may be useful in 2.5 atm. Watte! and associates1 1 dem-
Preoperative Care
:ngth evaluating wound healing potential. onstrated that healing will occm in Elements of preoperative care are
:hout Although current technology does 75% of patients in whom the TcPo 2 unique to each of the three etiologies.
away not allow transcutaneous oxygen level adjacent to the wou nd rises to These elements must be carefully con-
aring measurement at toe levels, tissue per- 100 mm Hg in the chamber. sidered to ensure the best possible
)n to Another method currently in use is outcome in terms of length preserva-
fusion can be evaluated from the
1 to a proximal thigh down to the distal laser Doppler velocimetry (LDV), tion and avoidance of complications.
Lil be dorsal metatarsal level. This test is which measures the mean velocity of
ue at useful in a logical selection of the red blood cells within skin capillaries. Trauma
,r re- small minority of patients who may Karanfilian and associates 12 com- One element unique to trauma is that
::tion, benefit from perioperative hyperbaric pared the value of TcPo 2 , LDV, and the patient may arrive with a com-
:l nu- oxygen therapy. Values greater than 30 segmental Doppler ankle pressures in pleted, but crude, amputation. Irrepa-

rable damage to the local circulation are also sometimes associated with
may have created limited areas of significant fractures proximal to the
nonviable tissue. In addition, areas of level of required amputation. Consid-
relative ischemia, induced by the eration should be given to the imme-
trauma itself, may either recover or diate or delayed reduction of and fix-
progress to local necrosis. Conse- ation of such fractures, rather than
quently, the best approach is to do automatically amputating through
conservative wound debridement ini- the most proximal fracture site. This
tially and await completion of demar- approach will help to retain maxi-
cation before definitive ablation. An- m um walking function in many pa-
tibiotics and o:>,.)'gen should be tients.
administered empirically, and all vaso-
constrictors, such as nicotine and caf- lschemia
feine, should be avoided. Transcuta- ln cases of dry gangrene, the etiology
neous oxygen measurements, with must be determined before embark-
oxygen challenge, may help to assess ing on definitive smgicaJ therapy so
the recovery of perfusion in trauma- that the underlying disorder can be
tized tissue. treated concomitantly. With the sud- A
In cases of major skin damage in den onset of severe localized ischemia
the foot, the location and total area associated with arterial thrombosis or FigurE
that is avulsed, devitalized, or severely embolization, arterial flow down to (B) sh
scarred must be considered. Complete the level of demarcation may be rela- disart
degloving of the foot or severe burn tively normal. When this occurs prox- Myen
Figure 5 Left lower limb of 43-year-old scarring, for example, are best treated imal to the metatarsophalangeal
man after complete degloving of the
with a long t.ranstibial amputation (MTP) joints, early amputation or
foot and ankle by a gear box on a con-
struction crane. The foot was totally in- (Figures 5 and 6). Partial degloving disarticuJation at the most distal level
sensate and contracted. Salvage was may be managed by various combina- that will allow immediate closure
attempted with split-thickness skin graft- tions of partial foot amputation fol- with viable locaJ flaps is usually indi-
ing. Transtibial amputation resulted in lowed by closure with sensate ski n in cated (Figure 7).
early rehab ilitation. (Reproduced with
permission from Bowker JH, San Giovanni
weight-bearing areas and split- If only the digits are involved, the
TP: Amputations and disarticulations, in thickness skin grafts in non-weight- maximum amotmt of toe length can
Myerson MS (ed): Foot and Ankle Disor- bearing areas. Although most areas often be preserved by allowing auto-
ders. Philadelphia, PA, WB Saunders, can be closed by these methods, loss amputation over a period of months.
2000.) of the heel pad with exposure of the Regular outpatient observation is
calcaneus may result in a transtibial mandatory w1til the process is com-
amputation if partial calcanectomy plete. If areas of inflammation occur
does not allow closure. Foot injuries at the boundary between the necrotic
A
Figu1
of al
t ions
(ed):
and
deb1
cal •
as
con·
ead
USU:
Figure 6 Feet of a 28-year-old man that were severely scalded at age 14 months. They healed with scar and split-t hickness skin grafts. Will
A, Dorsal view showing loss of toes. B, Plantar view showing bilateral painful ulcers. Patient eventually had bilateral transtibial ampu- (Fif
tations and then returned t o full-time work. (Reproduced with permission from Bowker JH, San Giovanni TP: Amputations and disar-
app
ticulations, in Myerson MS (ed): Foot and Ankle Disorders. Philadelphia, PA, WB Saunders, 2000.)
can

Chapter 34: Amputations and DisarticuJations Within the Foot: Surgical Management 433
~ith
the
sid-
me-
fix-
:han
,ugh
This
Lax:i-
pa-
>logy
>ark-
>y so
n be
sud- c
,emia
sis or Figure 7 Plantar views of feet of a 60-year-old man with lupus erythematosus and bilateral dry gangrene. Right foot (A) and left foot
m to (B) show good perfusion proximal to lines of demarcation. C, Eleven months after rad ical debridement of the right foot and Lisfranc
rela- disarticulation of the left foot. (Reproduced with permission from Bowker JH, San Giovanni TP: Amputations and disarticulations, in
Myerson MS (ed): Foot and Ankle Disorders. Philadelphia, PA, WB Saunders, 2000.)
prox-
mgeal
m or
l level
losure
· indi-
d, the
:h can
auto-
onths.
on is
: com·
occur
ecrotic
Figure 8 A, Feet of a 41-year-old man with acquired immunodeficiency syndrome who awoke from septic coma w ith partial necrosis
of all toes. Treatment consisted of keeping the toes dry and protected from trauma. B, Twenty months later, completed autoamputa-
tions are evident. (Reproduced with permission from Bowker JH, San Giovanni TP: Amputations and disarticulations, in Myerson MS
(ed): Foot and Ankle Disorders. Philadelphia, PA, WB Saunders, 2000.)
and viable tissue, a regimen of minor cause of health status yet has not de- Infection
debridement, oral antibiotics, and lo- veloped critical limb ischemia requir- Wet (infective) gangrene may spread
cal application of drying agents such ing a major amputation (Figure 9). along fascial planes and tendon
as povidone-iodine may avert the Most important, areas of dry gan- sheaths with alarming rapidity, abet-
conversion of dry to wet gangrene. As grene must never be treated with ted by several factors. Continued
each toe sloughs its necrotic portion, soaks, whirlpool baths, wet dressings, weight bearing, commonly seen in di-
usually through a joint, the wound or debriding agents. Moistening the abetic patients lacking protective sen-
in grafts. will have largely or completely closed juuction of viable and gangrenous tis- sation, causes the dispersal of pus ac-
al ampu- (Figure 8). This approach is especially sue encourages bacterial and fungal cumulating under pressure. As
nd disar·
appropriate when the patient is not a growth, converting an easily managed definitive treatment is delayed be-
candidate for limb bypass surgery be- condition to an emergent one. cause of lack of protective sensation

can l
incis
Balla
rior
dis ta
met~
bee
web
tbe <
of tl
info
dist,
Figure 9 A, Left foot of 77-year-old man with diabetes mell itus and a 30-year history of smoking. Note partial dry gangrene of the incii
lateral fou r toes. Vascular reconstruction was not feasible because of his cardiac status. B, Three months later, apparent gangrene had para
receded in all toes, and the fifth toe had sloughed through the proximal interphalangeal joint. C, Six months later, there was consid- obta
erable tissue salvage by allowing completion of autoamputation without surgical interf erence. (A and C are reproduced with permis- tion
sion from Bowker JH: Transtibial amputation, in Murdoch G, Wilson AB Jr (eds): Amputation Surgery: Surgical Practice and Patient
Management. Oxford, England, Butterworth-Heinemann, 7996, pp 43-58.) (B is reproduced with permission from Bowker JH, San Gio- sepa
vanni TP: Amputations and disarticulations, in Myerson MS (ed): Foot and Ankle Disorders. Philadelphia, PA, WB Saunders, 2000.) inte
bee,
sma
and attendant denial, single-species rectly p lantar to the metatarsal heads. excluded on the basis of etiology. obv
infections soon become polymicro- Incisions should be longitudinally Longitudinal rather than transverse and
bial. The wound can be probed with a oriented to avoid as many vascular amputation should be the goal when- sho
sterile cotton-tipped applicator. If and neural structures as possible. By ever functionally feas ible. Narrowing to <
bone is contacted, a presumptive di- turnecessarily extending an incision the foot rather than shortening it cov,
agnosis of osteomyelitis can be made, into the heel pad or proximal to the greatly simplifies postoperative shoe of r
even without the use of expensive ankle joint, a more proximal ablation, fitting. Conversely, the surgeon tot
bone scans. 13 Confirmation is ob- such as a Syme ankle disarticulation, should also consider the possibility and
tained by coned-down radiographs. may be severely compromised. that a failed forefoot or midfoot am- feet
Aerobic and anaerobic cultures The interdependence of serwn putation performed because of infec- spa
should be taken at this time, allowing glucose levels and infection control tion may eliminate the opportunity lati
presumptive selection of antibiotics relates to the negative effect of for a Syme ankle disarticulation. tio1
pending the results of cultures and chronic hyperglycemia on leukocyte Therefore, the surgeon must be rea- the
antibiotic sensitivity tests. Because function and on tissue resistance to sonably sure that the initial level se- an1
most diabetic foot infections are infection. Senun glucose control lection is logical. thi1
polymicrobial, broad-spectrum anti- should be initiated promptly, al- In cases of foot infection, a careful ula
biotics should be administered intra- though this may be difficult in the and thorough debridement is the first pu1
venously. The lengtb of foot tl1at can face of infection, reinforcing the need step. Although the preoperative ex- lllV
be salvaged is often profoundly af- for assistance from an internist as well amination, radiographs, and vascular pre
fected by the behavioral and temporal as early formal debridement of all ne- assessment provide valuable guid- siv,
factors already noted, so surgical crotic and infected tissue, including ance, at the beginning of debridement tin
debridement must be undertaken bone, in the operating suite. However,
tl1e surgeon cannot be certain of the po,
promptly to avert further tissue loss. it may be unsafe to strive for tight se-
full proximal extent of an infective ter
rum glucose control until tbe patient
If a definitive debridement must be process or the viability of remaining an,
is metabolically stable postopera-
delayed more than a few hours, the tissues. The patient and family should tre
tively.
abscess should be drained in the be told that the procedure is, there- as
emergency department to control fur- fore, somewhat exploratory in nature thi
ther spread of infection. This can be General Surgical and that based on further informa- m,
performed with or without ankle Technique (All tion obtained during the operation, str
block anesthesia, depending on the the surgeon will be as conservative as va.
severity of sensory loss from diabetic Levels) possible in removal of tissue. fo1
neuropathy. Decompressive incisions If the criteria for level selection are Both plantax and dorsal incisions le~
must respect all normal weight- met and the standards for wound may be required to fully drain all ab- se1
bearing skin surfaces such as the heel healing are correctly factored in, no scess pockets. All of the central plan- fu
14
pad, lateral sole, and the surface di- amputation level in the foot need be tar spaces described by Grodinsky co

Chapter 34: Amputations and Disarticu.lations Within the Foot: Surgical Management 435
can be opened by the extensile plantar

incision described by Loeffler and
sallard. 15 This incision begins poste-
rior to the medial malleolus and en ds
distally between the first and second
metatarsal heads. From there it may
be extended as deeply into the first
web space as necessary. Depending on
the extent of the infection, all or part
of this incision may be used. Distal
infections may track across the entire
distal foot pad, requiring a transverse
incision at the base of the toes. Two
'the
had parallel incisions may be required to
nsid- obtain full exposure of a do rsal infec-
rmis- tion, but they shou.ld be as widely
t ient
separated as possible. Even then, the
Gio-
) intervening skin bridge may necrose
because of septic thrombosis of its
smaU skin vessels. After removal of
logy. obviously necrotic tissue, the dorsal
verse and plantar surfaces of the foot
Figure 10 A, Right foot of 52-year-old woman with diabetes mellitus following disartic-
hen- should be firmly stroked proximally ulation of the fourth and f ifth toes and necrotic dorsal skin for wet gangrene. The
wing to distally along tissue planes to dis- wound is ready for split-thickness skin grafting on a bed of granulation tissue. B, Three
lg it cover and empty remaining pockets months after grafting. The graft has now tolerated shoe wear for many years. (Repro-
shoe of pus. These pockets are then probed duced with permission from Bowker JH: Partial foot amputations and disarticu/ations.
geon Foot Ankle Clin Nort h Am 1997;2: 153.)
to their proximal end, opened widely,
bility and debrided. If a severe midfoot in-
: am- fection is present but the heel pad is otherwise salvageable tissues in pres- is ideally formed of plantar skin, sub-
nfec- spared, an open Syme ankle disarticu- ervation of forefoot length. cutaneous tissue, and investing fascia.
unity lation is indicated. Extension of infec- Redebridement of a wou.nd may be Alth ough muscle tissue is an integral
1tion. tion along tendon sheaths proximal to necessary for several reasons. First, it part of the soft-tissue envelope in
: rea- the ankle joint or into the heel pad or is often difficult to be certain that all more proximal amputations, it is not
el se- ankle joint generally precludes any- infected and necrotic tiss ue has been available at all these levels. Adherence
thing but an open true ankle disartic- removed p rimarily. Second, some ar- of skin directly to bone must be min-
areful ulation and a delayed transtibial am- eas of skin that initially appeared via- imized to prevent u.lceration from
e first putation. Even when the extent of ble may have become frankly ne- shear forces during walking. This is
'e ex- involvement is initially uncertain, crotic. Finally, the infection may have best accomplished by avoiding cover-
scu.lar preliminary exploration with aggres- persisted despite the debridemen t and age with split-th ickness skin grafts on
guid- sive debridement rarely adds much antibiotic use. Therefore, manually the distal, lateral, and p lantar surfaces
ement time to the overall procedure. All stripping the infected areas from of the residual foot whenever possi-
of the poorly vascularized tissues, such as proximal to distal every 24 to ble.16 Conversely, split-thickness skin
fective tendons, joint capsules, volar plates, 48 hours to locate pockets of infec- grafts placed dorsally, even on granu-
aining and articular cartilage, should be tion that may have escaped initial de- lated bony surfaces, can last indefi-
.hould treated as foreign bodies and removed tection is a sound practice. Limited nitely with reasonable care (Figure
there- as part of a thorough debridement. If secondary debridements can be done 10). To prevent further damage to
nature this is not done, the wound may reat bedside or, if more extensive or the skin with compromised vascu.larity,
-0rma- main open for months until these patient requires ankle block anesthe- such skin should never be handled
ration, structures sequestrate. All well- sia, in the operating room. with forceps during surgery. Proper
tive as vascularized tissue shou.ld be saved When primary wound closure can contouring of all bone ends will pre-
for secondary reconstruction regard- be accomplished safely, other factors vent damage to the soft-tissue enve-
cisions less of configuration to assist in pre- should be considered. To absorb the lope from within wherever it is com-
all ab- serving foot length for maximum shear and direct (normal) forces gen- pressed between bone and the
1 plan- function. The gu.illotine approach, in erated during gait, the soft-tissue en- prosthesis, orthosis, or shoe. To pre-
. k . 14 contrast, will preclu.de creative use of velope must be mobile. The envelope vent equin us contracture of the ankle
ins 'Y

Figure 12 Right foot of a 46-year-old

man with diabetes mellitus who has os-
teomyelitis of the distal phalanx of the
second toe with mallet deformity of the
distal interphalangeal joint. Disarticula-
tion of the distal phalanx was curative.
Previous MTP disarticulation of t he great Figure 13 Medial shift of right fifth toe
toe left the insensate second toe exposed closed the gap from earlier disarticula-
to trauma. (Reproduced with permission tion of the fourth toe, restoring a smooth
from Bowker JH: Minor and major lower distal contour to the forefoot. No further
limb amputations in diabetes mellitus, in ulcerations occurred during an 8.5-year Figure
Bowker JH, pfeifer MA (eds): Levin and fol low-up period. (Reproduced with per- insens,
O'Neal's The Diabetic Foot, ed 6. St. mission from Bowker JH: Role of lower by the
Louis, MO, Mosby, 2001.) limb amputation in diabetes mellitus, in and sh
Levin ME, O'Neal LW, Bowker JH (eds): tribute
Figure 11 A, Right foot of a 49-year-old The Diabetic Foot, ed 5. St. Louis, MO, Bowke
man with diabetes mellitus who has wet is due to preservation of the flexor Mosby-Year Book, 1993, pp 433-455.) pfeifer
gangrene of the great toe and adequate 2001.)
hallucis brevis complex, including the
perfusion proximally. B, After interpha-
langeal disarticulation fol lowing conser- sesamoids and hence the windlass lar cartilage, the head should be
vative debridement and primary closure mechanism (Figure 11) . To achieve smoothed carefully with a file.
over Kritter flow-through irrigation sys- closure of the wound without tension, Dii
Osteomyelitis of the distal phalanx
tem. (Reproduced with permission from the :t,.,
trimming the condylar prominences of a lesser toe often occurs following
Bowker JH: Surgical techniques for con- probl,
serving tissue and function in lower-limb and shortening the proximal phalanx ulceration of a mallet toe associated
by removing the articular cartilage are suppc
amputation for trauma, infection, and with loss of protective sensation. This
vascular disease. Instr Course Leet 1990; quire,
often necessary. When a more radical is most commonly noted in the sec-
39:355-360.) (buni
resection of the proximal phalanx is ond toe in patients with a long second
bony
required, Wagner 17 recommends leav- metatarsal bone, especially following
sure t
joint in foot ablations proximal to the ing just its base, to keep both the ses- disarticulation of the great toe, but
amoids and the plantar fat pad be-
15).1
MTP joints, postoperative casting in may occur in any lesser toe (Figure
can 1:
slight dorsiflexion for 3 to 4 weeks is neath the metataJsa.l head. The joint 12) . Removal of the infected distal
capsule is left intact, helping to limit the I
recommended. By weakening the phalanx both shortens and straight-
proximal spread of infection. proxi
plantar flexors relative to the dorsi- ens the toe, reducing the risk of future
The first MTP joint is the next site toe. F
flexors, immobilization results in a re- ulceration.
first
sidual foot with better muscle bal- of election if the entire proximal pha- If the third or fourth toe a.lone is
inally
ance. lanx is involved. After division of the disarticulated, the adjacent toes will
rowir
flexor hallucis brevis insertions on the tend to close the gap and restore a
proximal phalanx, the sesamoid bones good
good contour to the distal forefoot
Toe Disarticulations will displace proximally, exposing the (Figure 13). Amputation of the fifth
16).
Method O,
prominent crista on the plantar sur- toe alone may leave a wide fifth meta-
face of the metatarsal head. The sesa- cur ii
Even when osteomyelitis is present in tarsal head prominent laterally. In this
the distal phalanx of the great toe, moids may also become troublesome chan,
case, the lateral condyle of the meta-
sufficient skin can often be saJvaged bony prominences just proximal to case,
tarsal head should be trimmed sagit-
to permit an interphalangeal disartic- the metataJSal head. For this reason tally. Leaving a lesser toe isolated by be ac
u.lation. The remaining proximal pha- the sesamoids, with their fibrocarti- removing toes on either side will in- age (
lanx will aid with balance and result laginous plate, should be excised and crease the susceptibility of the iso- the c
in a much better gait than results after the crista removed with a rongeur. lated toe to deformity and injury both
disarticulation at the MTP joint. This Following removal of the articu- (Figme 14). the -v

, toe
icula-
iooth
1rther
i-year Figure 14 A striking difference is evident in the distal forefoot contours of the pictured
I per- insensate right and left feet. On the right foot, the remai ning lesser toes are protected
fower by the great toe. On the left foot, the fourth toe is constantly exposed to minor trauma
US, in and should have been removed with the other lesser toes, leaving t he great toe to con-
(eds): tribute to forward propulsion and easy shoe f itting. (Reproduced with permission from
MO, Bowker JH: Minor and major lower limb amputations in diabetes mellitus, in Bowker JH,
.) Pfeifer MA (eds): Levin and O'Neal's The Diabetic Foot, ed 6. St. Louis, MO, Mosby,
2001.)
d be Figure 15 Result of right second toe dis-

articulation in an 87-year-old man w ith
Disarticulation of the second toe at ular cartilage and volar plates will in- diabetes mellitus. A, Hallux valgus defor-
alanx
the MTP joint may create a special crease the amount of skin available for mity secondary to loss of lateral support
>wing of second toe. B, Ulcer over bunion pene-
problem because it removes lateral closure (Figure 17).
:iated trating MTP joint. (Reproduced with per-
support from the great toe that is re-
. This mission from Bowker JH, San Giovanni
quired to prevent a hallux valgus TP: Amputations and disarticulations, in
~ sec-
(bunion) deformity. This iatrogenic Special Considerations Myerson MS (ed): Foot and Ankle Disor-
~cond ders. Philadelphia, PA, WB Saunders,
)Wing bony prominence may lead to a pres- Walking function will be most af-
2000.)
sure ulcer in an insensate foot (Figure fected by disarticulation of the great
!, but
15). The probability of this occurrence toe at the metacarpophalangeal joint
·igure
distal can usually be reduced by removing because the role of the first ray in the
great toe during active sports.
aight- the second metatarsal through its final transfer of weight during late
Whether significant problems will oc-
future proximal metaphysis· along with the stance phase is Jost. This effect was
cur with aging is not known, but to
toe. Following this ray amputation, the studied by Mann and associates 18 in
prevent this, the authors suggested
one is first and third metatarsals will nor- 10 patients with an average age of
that the base of the proximal phalanx
:s will mally approximate each other, nar- 23 years who had w1dergone pollici- be left to preserve the windlass mech-
tore a rowing the foot and resulting in a zation of the great toe. They found a anism or that the insertion of the
refoot good cosmesis and function (Figure shift in the end point of progression plantar aponeurosis and intrinsic
16). of the moving center of plantar pres- muscles be sutured into the distal
e fifth
meta- Occasionally, dry gangrene will oc- sure during stance from the second metatarsal to stabilize it. 18 These
In this cur in all five toes without significant metatarsal head to the third. This oc- measures may not be possible in cases
meta- change in perfusion proximally. In this curred despite a dropping of the first of infection or severe trawna. Loss of
sagit- case, disarticulation of all five toes can metatarsal head following loss of the lesser toes, in contrast, appears to
ted by be accomplished with primary cover- great toe and its stabilizing windlass cause little d inical difficulty. Walking
rill in- age of the metatarsal heads, provided mechanism. In this group, reported impairment fo llowing great toe disar-
1e iso- the dorsal and plantar incisions are symptoms after an average of 3 years ticulation is minimized by provision
injury both made as far distally as possible in were minimal except for difficulty in of a shoe with a stiff sole, molded soft
the web spaces. Removal of the aritic- movements requiring flexion of the insert, a nd filler.

I
J
Figure 16 Left foot of a woman w it h diabetes mellitus who has osteomyelitis of the second ray from a penetrating ulcer beneath the
prominent metatarsal head. A, Dorsal view demonstrates swelling centered over the second ray. B, lntraoperative view shows dissolu-
tion of the metatarsal neck and resected ti:ssue. C, Postoperative view shows forefoot narrowing with no signif icant hallux valgus be-
cause of lateral support provided by the third toe.
Figu1
fecti ,
colu1
is ev
atio,
4:23·
Ra
Me
In r
all
Wit:
met
asp
tion
cust
The
witl
tiOlll
sim
feet
Figure 17 A, Right foot of a 63-year-old woman w it h lupus erythematosus and dry gangrene caused by microemboli. B, lntraoperative
view showing partial closure after disarticulation of all f ive toes and debridement of necrotic dorsal skin. Because of arteritis, postop· the
erative hyperbaric oxygen treatments were given. The dorsa l defect healed by wound contraction. C, Seven years later, patient has ex· tot
cellent gait in a rocker-soled shoe with custom inlay. (A and Care reproduced w it h permission from Bowker JH: Partial foot amputa· hea,
tions and disarticulations. Foot Ankle Clin North Am 1997;2:153.) (Bis reproduced with permission from Bowker JH, San Giovanni TP: erac
Amputations and disarticulations, in Myerson MS (ed): Foot and Ankle Disorders. Philadelphia, PA. WB Saunders, 2000.)
infe
sha:
me1
mir
rov.
sho
American Aca.demy of Orthopaedic Surgeons

Figure 19 Right foot of a man with dia-

betes mellitus who underwe-nt fourth ray
amputation for osteomyelitis that heated
by secondary intention. Narrowing of the
th the
forefoot and excellent distal forefoot
issotu-
contour are evident. (Reproduced with
us be-
permission from Bowker JH, San Giovanni
B TP: Amputations and disarticulations, in
Myerson MS (ed): Foot and Ankle Disor-
Figure 18 A, Radiograph of a left foot after radical first ray amputation for diabetic in- ders. Philadelphia, PA, WB Saunders,
fection. Insufficient metatarsal shaft remains for effective orthotic support of the medial 2000.)
column. B, Planovalgus position of the foot secondary to loss of medial column support
is evident. (Reproduced with permission from Bowker JH: Medica l and surgical consider-
ations in the care of patients with insensate dysvascular feet. J Prosthet Orthot 1992;
4:23-30.)
Ray Amputations pect to avoid an area of increased

pressure during latter stance phase.
Methods
A single amputation of ray 2, 3,
In ray amputation, a toe and part or or 4 affects o nly the width of the fore-
all of the metatarsal are removed. foot. Resection should be performed
With the fu-st or medial ray, as much through the proximal metaphysis
metatarsal shaft length should be left where the involved ray intersects with
as possible to allow for effective eleva- the adjacent metatarsals, leaving the
tion of the medial arch with a tarsometatarsal joints intact (Figure
custom-molded insert (Figure 18). 19). The fifth metatarsal should be
The insert should be fitted into a shoe transected obliquely with an infero-
with a rigid rocker bottom. Preserva- lateral-facing facet . The uninvolved
tion of first metatarsal length is often half to three quarters of the shaft is left
simple because the usual cause of in- to enhance the weight-bearing area
>perative
fection is a penetrating ulcer under and to retain the insertion of the per-
• postop- the first metatarsal head. In addition oneus brevis tendon (Figure 20) .
1t has ex- to the great toe, only a portion of the In cases of massive forefoot infec- Figure 20 Left foot of a woman with di-
amputa- abetes mellitus who underwent fifth ray
bead may need to be removed to tion, multiple lateral ray resections amputation. The proximal half of the
vanni TP: eradicate the infection, leaving all un- may be required. In this situation, the shaft was left to maintain the weight-
infected portions of the head a nd lateral metatarsals can be divided ob- bearing area and retain the insertion of
shaft. The extent of osteomyelitis in a liquely, with each affected metatarsal the peroneus brevis tendon. (Reproduced
metatarsal can generally be deter- being cut somewhat longer with pro- with permission from Bowker JH: Minor
and major lower limb amputations in di-
mined visually. Curettage of the mar- gression toward the first ray (Figure abetes mellitus, in Bowker JH, Pfeifer MA
row cavity is recommended . The bone 21) . If all but the first ray are involved, (eds): Levin and O'Neal's The Diabetic
should be beveled on the plantar as- the first ray can be left complete (Fig- Foot ed 6. St. Louis, MO, Mosby, 2001.)

ure 22) . This strategy will retain both

rollover function and full foot length
in the shoe and, with proper pedorthic
fitting, is preferable to a transmetatar-
sal amputation: 7 ' 19•20 Removal of two
or more medial rays is a poor choice,
both functionally and cosmetically, as
is removal of two or more central rays
(Figure 23). ln any ray amputation, the
inciting ulcer is easily excised with a
No. 11 blade through the full thickness Figurt
of the tissues plantar to the bone. lf the the IE
resulting wound is clean and small mellit
enough, it can be closed primarily fectec
with a single deeply spaced skin su- plant;
meta1
Figure 22 Right foot of a 62-year-old ture. Otherwise, it can be left open to etrati
man with diabetes mellitus 3 years after contract and heal secondarily. amoic
the lateral four rays were excised ob- from
Figure 21 Left foot of a man with diabe- liquely for a severe foot abscess. The first Special Considerations and
tes mellitus who underwent fourth and ray is intact. Walking fu nction w ith a cus- North
fifth ray amputations. He walks well in an tomized shoe is excellent with preserva- Major reduction of first metatarsal
in-depth shoe with custom -molded inlay tion of the medial arch and rollover in length is devastating because an intact
and lateral filler. (Reproduced with per- terminal stance. (Reproduced with per- medial column is essential to proper
mission from Bowker JH, San Giovanni mission from Bowker JH, San Giovanni foot balance during both stance and
TP: Amputations and disarticulations, in TP: Amputations and disarticulations, in
Myerson MS (ed): Foot and Ankle Disor- Myerson MS (ed): Foot and Ankle Disor-
forward progression. The effectiveness
ders. Philadelphia, PA, WB Saunders, ders. Philadelphia, PA, WB Saunders, of orthotic restoration of the medial syste1
2000.) 2000.) arch will depend on the length of first TemE
metatarsal shaft preserved. Single ner"
lesser ray amputations can provide an
excellent result both functionally and
cosmetically. Because only the width
Tra
of the forefoot is reduced, rollover An
function and overall foot balance dur- Me1
ing terminal stance appear to remain
Tran:
essentially normal. Proper pedorthic
be cc
fitting can compensate for removal of
dial t
several lateral rays when done conser-
mus t
vatively. Barefoot walking is impaired
func1
in all but the single lesser ray amputa-
mud
tions.
cove1
When a penetrating ulcer destroys
tally,
the first MTP joint, leaving the great
toe viable, rather than a first ray am- tally
putation, the joint alone can be re- ual d
moved through a medial longitudinal with
incision. The inciting ulcer should be good
excised as described above. All avas- dowr
cular tissues, including the sesamoid assis1
complex, remaining articular carti- lengt
lage, joint capsule, tlexor tendons, and the
infected cancellous bone, should be skin,
Figure 23 A, Radiograph of the right foot o f a man w ith diabetes mellitus after excision removed. Tbe extensor hallucis lon- skin
of the three central rays for an abscess. (Reproduced with permission from Bowker JH: gus tendon can usually be retained the
Minor and major lower limb amputations in diabetes mellitus, in Bowker JH, Pfeifer MA (Figures 24 and 25) . If the wound ap- trim1
(eds): Levin and O'Neal's The Diabetic Foot, ed 6. St. Louis, MO, Mosby, 2001.) B, The cos- tensi,
metic and functional result is poor. Transmetatarsal amputation was required to correct
pears dean at the conclusion of the
chronic plantar ulceration. Initial oblique excision of all lateral rays might have pre- procedUie, it can be closed loosely tneta
vented this outcome. over a Kritter flow-through irrigation Withi

Ch apter 34: Amputations and Disarticulations Within the Foot: Surgical Management 441
)th
gth
hie
:ar-
:wo
ice,
•, as
:ays
the
:h a
1ess Figure 24 lntraoperative medial view of Figure 25 Right foot of a man with diabetes mellit us 14 months after excision of t he
'the the left forefoot of a man w it h diabetes f irst MTP joint for septic arthrit is. A, In active dorsif lexion, the ext ensor hallucis longus
nail rnellitus after excision of a chronically in- was intact. B, W hen active plantar flexion is attempted, absence of extension cont rac-
irily fected first MTP joint demonstrates the ture is evident. (Reproduced with permission from Bowker JH, San Giovanni TP: Ampu-
plantar bevel of t he distal metatarsal tations and disarticulations, in Myerson MS (ed): Foot and Ankle Disorders. Philadelphia,
su-
rnetaphysis. Joint infection followed pen- PA, WB Saunders, 2000.)
n to etration from an ulcer plantar to the ses-
amoids. (Reproduced with permission
from Bowker JH: Partial foot amputations
and disarticulations. Foot Ankle Clin
North Am 1997;2:153.)
arsal
1tact
oper
and
iness
edial system,2 L which is described later.
' first Temporary stabilization with Kirsch-
ingle ner wires may be useful in some cases.
:le an
r and
,.ridth
Transmetatarsa I
fover Amputation A
: dur- Method
:main Figure 26 Dorsal (A) and lateral (B) views of an ideal t ransmetatarsal amputation. Note
Transmetatarsal amputation should
>rthic the posit ion of the distal plantar flap, t he overall length of t he residual forefoot, t he
be considered when two or more me-
val of maintenance of the medial arch, and the absence of equinus deformity. (Reproduced
dial rays or more than one central ray with permission from Bowker JH: Minor and major lower limb amputations in diabetes
mser-
must be amputated. For maximtun mellitus, in Bowker JH, Pfeifer MA (eds): Levin and O'Neal's The Diabetic Foot ed 6. St.
>aired Louis, MO, Mosby, 2001 .)
function, it is important to save as
1puta-
much metatarsal shaft length as can be
covered with good plantar skin dis-
stroys
tally, avoiding the use of skin graft distal first metatarsal if possible. The 15° amputation should prevent equinus
great
yam- tally and plantarly (Figure 26). Resid- transverse angle that parallels the deformity. If no passive dorsiflexion is
be re- ual dorsaJ defects are easily managed metacarpophalangeal joints and nor- present, a percutaneous fractional
udinal with split-thickness skin grafts, with mal toe break of the shoe should be re- lengthening is indicated to reduce dis-
uld be good assurance they will not break produced. Plantar beveling of the tal p ressures over the metatarsal shafts
avas- down later with proper footwear. To metatarsal shafts will reduce distal followed by provision of an appropri-
amoid assist in obtaining maximum forefoot plantar pressures during gait. If a large ately padded ankle-foot orthosis.
carti- length and to ensure distal coverage of plantar forefoot ulcer is present, it can (AFO). If drop foot is present second-
1s, and the metatarsal shafts with durable be excised in a longitudinal elliptical ary to nerve trauma, transfer of a pos-
uld be skin, plantar and dorsal transverse manner and the wound closed in a "T" terior muscle-tendon unit may also be
is lon- skin incisions are made at the base of fash ion (Figme 27) . A Kritter flow- performed for its tenodesis effect. A
:tained the toes. At closme, the flaps are through irrigation system is useful in well-padded rigid dressing should be
.n d ap· tr immed to fit without redundancy or removing detritus. If the patient has applied before discharge with the foot
of the tension . To help preserve length, the active or passive ankle dorsiflex:ion in a plantigrade or slightly dorsiflexed
loosely metatarsal cuts shouJd begin medially, above a neutral position, postopera- position to protect the wo1rnd and
igation within the cancellous bone of the dis- tive casting following transmetatarsal prevent equinus contracture. The cast

unnecessary and that the incision tibii,

should not traverse infected areas. Care
They also reported a satisfactory out- ima
come in walking function in 78% of gus
patients. mec
Following transmetatarsal amputa- the
tion, the shoe sole should be fitted can
with a steel shank or carbon fiber met
stiffener with a rocker to avoid distal pro:
uJcers from a flexible sole wrapping the
aro und the end of t he resid ual foot. A in p
distal filler will also be needed to tran
maintain the shape of the toebox. foui
Figure 27 lntraoperative view of a right Some patients may elect a custom- late,
transmetatarsal amputation in a 62-year- made short shoe, but because of the the
old man with diabetes mellitus. Infection
was init iated by a large penetrating ulcer
shortened forefoot lever arm this will the
beneath the second metatarsal head. result in an unequal drop-off gait. ten<
Wide elliptical excision of the ulcer re· Another option for a short transmeta- avoi
quired a T-shaped closure. The Kritter tarsal amputation is an AFO with an pen
flow-through irrigation system w ith
anterior shell to provide improved len!
w idely spaced sutures allows egress of ir-
rigation fl uid. (Reproduced with permis- stability and balance. A variety of in- of;;
sion from Bowker JH, San Giovanni TP: framalleolar prostheses for trus level pla.1
Amputations and disarticulations, in My· have been successful1y fitted. sitic
erson MS (ed): Foot and Ankle Disorders. Figure 28 "Hidden amputation" of For selected lesions involving sev- bee:
Philadelphia, PA, WB Saunders, 2000.) Baumgartner, used in lieu of transmeta-
eral metatarsals in which the toes are len!
tarsal amputation. Diagram shows the
position of t he toes, which have retracted intact, in lieu of a transmetatarsal the
is changed weekly until the wound is to the level of proximal bony resection amputation, Baumgartner20 has de- 3 tc
sound, when a shoe with filler and stiff after about 6 months. (Reproduced with scribed a "hidden ampu tation." In this sur,
permission from Baumgartner R: Forefoot procedure, the distal two thirds of (Fi!
rocker sole and any indicated AFO
and hindfoot amputations, in Surgical I
previously fabricated can be each metatarsal is resected through
Techniques in Orthopaedics and Trauma-
cancellous bone. After about line
fitted . tology. Paris, France, Elsevier SAS, 2001,
p 3.) 6 months, with soft-tissue contrac· ula1
tion, the toes retract to th e level of thrc
Special Considerations proximal bony resection (Figure 28). cub
becoming independent walkers. Un- dial
Published healing rates for transmeta- fortunately, the authors provided no tior
tarsal amputations have varied widely. long-term data regarding durabiHty Tarsometatarsal whi
Geroulakos and May2 2 noted healing of the scarred or grafted wounds. 24
in 68% of a group of 34 diabetic and
{Lisfranc) thir
Pinzur and associates 25 reported 81 % pro
nondiabetic patients with dry gan- healing in 58 patients with both short
Disarticulation dor
grene, but no follow-up regarding transmetatarsal amputations and Lis- Method Bat
function was offered. Hobson and as- franc disarticulations. Again, func- Disarticulation at the tarsometatarsal the
sociates23 reported a 50% healing rate tional follow-up data were not pro- joints, described by Lisfranc27 in ven
in 30 amputees selected for gangrene, vided. The work of McKjttrick and 1815, is most useful in cases of onJ
rest pain, or infection; likewise, the associates,26 published in 1949, dem- trauma and selected cases of foot tu· sio1
authors presented no functional data. onstrates what a high level of clinical mor. It can also be used in cases of in· fra1
Both groups of patients were chosen actunen can ach ieve. Prior to the fection, if patients are selected care- ove
for this level of amputation on clini- availability of any laboratory determi- fully so as not to risk failure of a Syme cau
cal grounds alone, including extent nations of tissue perfusion, th e au- ankle disarticulation. With a signifi· dor
of gangrene and skin appearance. thors obtained healing in 196 of 215 cant loss of forefoot lever length, the
Durham and associates 24 reported diabetic patients (91%) . Criteria for massive triceps surae can easily over·
that 53% of 43 open transmetatarsal healing included gangrene limited to power the relatively weaker dorsiflex:· Sp
amp utations healed by wound con- the toes, controlled infection, absence ors, leading to equinus contracture. Tar
traction or split-thickness skin graft- of dependent rubor, and a venous fill- To help maintain a balanced residual resc
ing in a mean time of 7.1 ± 5.6 ing time of less than 25 seconds. They foot, the insertions of the peroneus Wit
months, with 21 of 23 patients (91 %) noted that palpable pedal pulses were brevis, peroneus longus, and anterior bar

sion tibial tendons must be preserved.

reas. Careful dissection will spare the prox-
out- imal insertions of the peroneus lon-
Vo of gus and anterior tibial tendons on the
medial cuneiform. As reinforcement,
,uta- the distal insertions of these tendons
itted can be carefully dissected off the first
fiber metatarsal base and sutured to the
listal proximal slips. The "keystone" base of
,ping the second metatarsal should be left
ot. A in place to help preserve the proximal
d to transverse arch. The first, third, and
~box. fourth metatarsals can be disarticu-
tom- lated, while a portion of the base of
£ the the fifth metatarsal is left to preserve
swill the insertion of the peroneus brevis
gait. tendon. Equinus contracture can be
neta- avoided by performing a primarily
th an percuta neous fractional heel cord
Figure 29 Lateral views of t he right foot of a young man w ith traumatic Lisfranc disar-
roved lengthening fo llowed by application
ticulation demonstrate the range of ankle motion achieved by preservation of the mid-
)fin- of a rigid dressing with the foot in a foot insertions of the extrinsic muscles and postoperative casting in dorsiflexion.
level plantigrade or slightly do rsiflexed po- A, Maximum active dorsiflexion. B, Maximum active plantar flexion. (Reproduced with
sition.4 Another method that has permission from Bowker JH, San Giovanni TP: Amputations and disarticulations, in My-
been successful in lieu of heel cord erson MS (ed): Foot and Ankle Disorders. Philadelphia, PA, WB Saunders, 2000.)
~ sev-
es are lengthening is cast immobilization of

1tarsal the residual foot in dorsiflexion for
fai rl y normal late-stance-phase gait, a sidual foot by attachmen t of the ante-
.S de- 3 to 4 weeks to weaken the triceps
customized close-fitting fixed-ankle rior tibial tendon to the talus, either
.fl this surae relative to the ankle dorsiflexors
prosthesis or orthosis is typically pre- through a drill hole in the taJar head
·ds of (Figure 29) .
scribed. This is then placed into a or with sutures or staples to a groove
rough In the Bona-Jaeger procedure, the
shoe with a rigid rocker bottom. in the head. 28 To further restore a rel-
about line of resection is between the navic-
ative balance between dorsiflexors
ntrac- u]ar and cuneiforms medially, th en
and plantar flexors, I have found re-
vel of through the cancellous bone of the
moval of 2 to 3 cm of the Achilles ten-
: 28). cuboid laterally in line with the me- Midtarsal (Chopart) don to be more effective than length-
dial disarticulations. Careful dissec- Disarticulation ening it. This is accomplished
tion will preserve the plantar arteries,
which lie adjacent to the second and
M ethod through a separate longitudinal inci-
third cuneiform bones. Although the The Chopart disarticulation is sion, leaving the sheath of the tendon
procedure p reserves some foot length, through the talonavicular and calca- in place to allow rapid reconstitution
dorsifl.exion power is diminished. neocuboid joints. Like the Lisfranc at its new length. A rigid dressing
Baumgartner 20 recommends fusion of disarticulation, it is most useful in should be applied with the hindfoot
a tarsal the midtarsal (Chopart) joints to pre- trauma and selected cases of foot tu- in slight dorsitlexion for about
c21 in vent their secondary dislocation, but mor. It is rarely applicable to diabetic 6 weeks to prevent equinus contrac-
ses of only if normal sensation and perfu- foot infections because of the proxim- ture of the hindfoot as well as allow
:>ot tu- sion are present. Tarsometatarsal (Lis- ity of th e infection to the heel pad. At secure healing of the anterior tibial
5 of in- franc) disarticulatioo is preferred the time of disarticulation, all ankle tendon to the talus. Removal of the
:i care- over the Bona-Jaeger procedure be- dorsiflexors are divided. Without res- sharp anteroinferior corner of the cal-
a Syme cause of preservation of the ankle toration of dorsiflexor function and caneus is also recommended to pro-
signifi- dorsitlexion insertions. weakening of the p lantar flexors, se- vide comfortable stance and gait.
;th, the vere equinus deformity from myo- Marquardt29 believes that anterior
y over- static contracture of the unopposed tibial tendon transfer to the talus
,rsiflex- Special Considerations triceps surae is inevitable, with weight alone is inadequate because the trans-
racture. Tarsometatarsal disarticulations rep- bearing becoming painful as it shifts ferred muscle elevates only the talus
:esidual resent a major loss of forefoot length from the heel pad to the distal talus while the continued plantar flexion
eroneus with a corresponding decrease in and calcaneus. Active dorsiflexion can force on the calcaneus by the triceps
interior barefoot walking function. To restore be restored to this extremely short re- surae produces separntion and insta-

444 Section Ill: Th e Lower Limb
equim
prever
neal iJ
Spec
A1tho1
does a
inben
ervati,
ble hi
witho
tance~
proce,
essent
Jimb-
prostl
walkiJ
prostl
a rigi
Figure 30 Marquardt tenomyoplastic modification of the midtarsal (Chopart) disarticulation w ith triple dorsiflexor tenodesis. A, Lat-
eral intraoperative view of the left foot (toes to left). The anterior t ibial tendon is retracted medially, and the extensor hallucis longus quire,
tendon is retracted distally. Note the extensor digitorum longus tendons and the length of the plantar flap. B, Anterior view shows phase
two longitudinal grooves in the talus (to left) and one in the calcaneus (right). The grooves will receive t he anterior tibial, extensor
hallucis longus, and extensor digitorum longus tendons. C, The tendons are in place, sutured to t he plantar capsular and fascia l struc·
tures. D, Full-thickness plantar flap (to left) includes short f lexor muscle bellies for distal padding. E, Completed procedure with drain lm r
just before casting. Note the plantigrade position of the heel pad. F, Lateral radiograph after Marquardt modif ication demonstrates
range of active dorsif lexion and plantar flexion. (Courtesy of Professor G Neff.) Po!
Ma
Prim,
bility of the subtalar joint over time. throdesis of the subtalar joint with for ail
He has developed a tenomyoplastic transfer of the anterior tibial tendon cases
operation that elevates both bones. to the lateral border of the residual foreit
The anterior tibial and extensor hal- foot. The heel pad again becomes larly
lucis longus tendons are placed in plantigrade, and the vertical clearance comr
separate grooves in the talar head, and for a prosthetic foot is increased by prOCE
the common extensors are placed in l to 2 cm (Figure 32). 10 c

another groove in the anterior calca- Some cases of equinus contracture redet
neus. With the hindfoot held in dorsi- following Chopart disarticulation can chao,
flexion, the tendons are sutured to the be treated without reattaching the WOUJ
plantar capsular and fascia! structures dorsiflexors. Active dorsiflexioo with In

(Figure 30). The hindfoot is casted in restoration of heel pad weight bearing fectic
dorsiflexion until the tenodeses are is obtained by partial Achilles tendon initia
sound. excision and cast immobilization for folio'
Baumgartner20 recommends post· 3 to 4 weeks with restoration of com- mise,
operative external fixation of Chopart fortable prosthetic gait. This sin1ple maq
disarticulations to limjt equinus de- salvage procedure, recommended by wow
Figure 31 Diagram showing amount of formity. Nonetheless, he anticipates Burgess, 30 avoids revision to a Syme be cl
bone removed from the talus and calca- what he considers inevitable equinus ankle disarticulatioo or higher level inig;
neus to provide a smoother, more com- contracture by reshaping the distal ta· (Figure 33). ethyl
fortab le end-bearing surface in the event into
of an equinus deformity. The amount of lus and calcaneus to aUow less painful Because a prosthesis for this level
bone resected in the zone demarcated by anterior weight bearing in equinus eliminates both ankle and subtalar adj a<
lines A·A and B·B depends on t he quality (Figure 31). The heel pad, of course, motion without necessarily preventing need
and quantity of soft tissue available for is not plantigrade. If weight bearing deformity, several authors have rec- the c
closure. (Reproduced with permission becomes painful because of severe ommended arthrodesis of both the cone
from Baumgartner R: Forefoot and hind- The
foot amputations, in Surgical Techniques
equinus, Baumgartner20 recommends subtalar and ankle joints following
in Orthopaedics and Traumatology, Paris, lengthening of the Achilles tendon Chopart disarticulation. 3 1•32 They cite wide
France, Elsevier SAS, 2001, p 4.) followed by wedge resection and ar- advantages of absolute prevention of the I

eguinus deformity by ankle fusion and

prevention of progressive talocalca-
neal instability by subtalar fusion.
special Considerations
Although Chopart disarticulation
does allow direct end bearing, it has no
inherent rollover function. With pres-
ervation of full limb length and a sta-
ble heel pad, the amputee can walk
without a prosthesis for short dis-
tances. This is in contrast to the Syme
procedure, after which a prosthesis is
essential to both heel pad stability and
Limb-length equality. Nonetheless, the
prosthesis is essential for functional
walking. A close-fitting rigid ankle
prosthesis or ortbosis and a shoe with
Lat-
a rigid rocker sole are generally re-
ngus quired to permit good late-stance- Figure 32 Corrective surgery for severe painful equinus in a Chopart residual foot. The
lOWS phase gait. drawing on t he left illustrates t he deformity and amount of bone to be removed for
insor wedge resection of t he subtalar joint. Drawing on the right shows (1) Achilles tendon
truc- lengthening with restoration of the plantigrade hindfoot and (2) complet ed subtalar
:lrain Immediate arthrodesis with internal fixation. (Reproduced with permission from Baumgartner R:
rates Forefoot and hindfoot amputations, in Surgical Techniques in Orthopaedics and Trau-
Postoperative matology, Paris, France, Elsevier SAS, 2001, p 4.)
Management
Primary closure is usually indicated
with for ablation as a result of ischemia. In
1don cases of trauma, however, discovery of
ldual foreign material or removal of vascu-
)mes larly compromised tissue may be in-
:ance complete at the conclusion of the first
d by procedure. Secondary closure at 7 to
10 days, following any necessary
cture redebridement, greatly reduces the
1 can chances of infection and subsequent
; the wound dehiscence.
with In some cases of low-grade foot in-
aring fection, if the wound had little or no
ndon initial purulence and is visually clean
n for following debridement (no compro-
com- mised tissue or residual pus), a pri-
imple mary loose closure can be done. If the
~d by wound has sufficient volume, it can
Syme be closed over a Kritter flow-through
level irrigation system. 2 1 A 14-gauge poly-
eiliylene venous catl1eter is passed A
; level into tl1e depths of the wound from an
btalar adjacent site by means of its integral Figure 33 Medial views of the right foot of a 17-year-old man with a traumatic Chopart
inting needle. The needle is discarded and disarticulation. He presented with distal anterior pain w hile walking in a prosthesis sec-
e rec· the catheter is sutured to the skin and ondary to severe equinus deformity. These photographs were taken 3 weeks after exci-
sion of 2 cm of Achilles tendon and casting in dorsiflexion to restore t he plantigrade po-
b the connected to a bag of normal saline.
sition of t he hindfoot. Note t he medial incision. A, Maximum active dorsiflexion.
owing The fluid ex.its the wound between B, Maximum active plantar flexion. (Reproduced with permission from Bowker JH, San
ey cite widely spaced simple skin sutures at Giovanni TP: Amputations and disarticulations, in Myerson MS (ed): Foot and Ankle Dis-
ion of the rate of 1 L per day for 3 days (Fig- orders. Philadelphia, PA, WB Saunders, 2000.)

cast ·
oper:
moti
ablat
prott
beari
SU I
Amp
with
Figure 34 A, Wet gangrene of the right great toe in a man with diabetes mellitus. The vant,
phalanges were infected, but some lateral skin was salvageable. Forefoot perfusion was inclu
adequate. B, Closure of the MTP disarticulation with a lateral toe flap. Note the w idely prop
spaced sutures, which allow egress of irrigation fl uid, and the catheter sutured to the
neur
skin.
full 1
pros1
ure 34) . The fluid, containing residual posed, a wet-to-wet method is useful. tive t
wound detritus, is collected in an ab- Four hours after each dressing and
sorbent dressing (Figure 35). The cha11ge, the dressing is rewetted exte- even
outer layers of the dressing are riorly with saline to prevent critical for I
Figure 35 Kritter flow-through irrigation
changed every 4 to 5 hours.33 After tissues from drying. Repeated expo- ene1q
system installed in a left second ray am-
removal of the system on the tbfrd sure of the wound surface to putation wound at conclusion of surgery. els Sl
day, the edges of the wound are gently povidone-iodine or hydrogen perox- Note the bulky bandage used to absorb amp·
compressed by the surgeon. If any ide can be cytotoxic to granulation irrigation fluid; the outer of the three tant
signs of purulence are present, the su- tissue and is not recommended.34•35 If rolls is replaced every few hours. amp
tures are removed and wound pack- Pseudomonas colonization occurs, as sult i
ing commenced. If patients have been evidenced by a greenish tinge to the age,,
carefully selected, however, purulence dressing, a 0.25% solution of acetic mation of granulation tissue catio
should be uncommon. The chief ad- acid can be used for a few days to throughout the depths of the wound. pros;
vantage is primary healing, usually suppress it. Use must be limited be- The diabetologist consulted to assist v,
within 3 weeks. The need for second- cause its bactericidal activity is ex- with preoperative control of serum WOUJ
ary closure or healing by secondary ceeded by its fibroblast toxicity. 36 glucose levels should provide the pa- and
intention over several months, often Maceration of the wouud by soaks or tient with a management program prov
augmented by skin grafting, is whirlpool treatments is not inclicated. that will continue to assist in wound tion
avoided. Every 24 to 48 hours, the surgeon heal ing after discharge by decreasing geon
The management of open amputa- should manually strip the wound tissue glycation. cons
tions or disarticu lations resulting from proximal to clistal to locate pre- The most important aspect of or f<
from trauma or infection is quite viously undetected pockets of infec- postoperative management in these amp
straightforward. Moderately wet sation, which may require debridement. cases is patient compliance with the trau1
line gauze dressings, gently packed Pre- and postoperative nutritional program. This includes avoidance of con<:i
into all recesses of the wound, are ap- support must include sufficient ca- weight bearing until the wound is
propriate in most cases. The advan- loric intake to compensate for a poor sound enough for suture removal, ad-
tages of this method are low cost and initial serum albumin level, as well as equate nutJ'ition, avoidance of vaso- Re·
ease of execution. Requiring only the catabolic effects of infection and constrictors such as nicotine and caf-
l. B
clean technique, it is easily taught to bed rest. Multivitamins as well as ad- feine, and tight control of serum
a1
the patient and family members be- ditional iron, zinc, and vitamin C glucose levels in patients with cliabe- i\
fore discharge. The dressing is provide essential elements for col- tes mellitus. Walking should be lim- 2. lv
changed every 8 hours, which is suffi- lagen formation in wound heal- ited to tl1e absolute mini.mum, and G
cient time for the gauze to adhere to iog.37•38 Oral hyperalimentation in the foot should be kept elevated ti
the wound surface and debride detri- patients with diabetes mellitus will re- whenever the patient is not walking to J
tus with each change. lf the wound is quire appropriate adjustments of hy- reduce the negative effect of edema 3.1',
producing excessive fluid, the gauze poglycemic medication to prevent on wound healing. During the fi rst b
may be used dry until this ceases. iatrogenic hyperglycemia. Before dis- few weeks, the wound should be eval· .t\,
Conversely, if the wound is too dry, or charging the patient to outpatient sta- uated weekly. In the case of closed
if a vital tendon or joint capsule is ex- tus, the surgeon should observe for- wounds, the partial weight-bearing

cast can be removed at 3 weeks post- peripheral vascular disease. Level se- 15. Loeffler RD Jr, Ballard A: Plantar fas-
operatively, and ankle and subtalar lection and alterna tive options, in cia! spaces of the foot and a proposed
motion res umed. In t he case of open Bowker JH, Michael JW (eds): Atlas of surgical approach. Foot Ankle 1980;1:
ablations, it is often possible to all ow Limb Prosthetics: Surgica~ Prosthetic 11-15.
and Rehabilitation Principles, ed 2. 16. Harris WR, Silvers tein EA: Partial am-
protected weight bearing, using heel-
Rosemon t, IL, American Academy of p utations of the foot: A follow- up
bearing weight-relief shoes.
O rthopaedic Surgeons, 2002, pp 25- study. Can J Surg 1964;7:6- ll.
38. (OriginaUy published by Mosby- 17. Wagner FW Jr: Partial- foot amp uta-
Year Book in 1992.)
summary tions: Surgical procedures, in Bowker
4. Livingston R, Jacobs RI, Karmody A: JH, Michael JW (eds): Atlas of Limb
Amputations and disarticulatio ns Plantar abscess in the d iabetic patient. Prosthetics: Surgical, Prosthetic and Re-
within the foot offer important ad- Poot Ankle 1985;5:205-213. habilitation Principles, ed 2. Rosemont,
vantages over more proximal levels, 5. Cianci P, H unt TK: Adj unctive hype r- IL, Ame rican Academy of Or thopaedic
including direct weight bearing w ith baric oxygen therapy in tr eatment of Surgeons, 2002, pp 389-401 . (Origi-
proprioceptive feed back alo ng no rmal d iabetic foot wo unds, in Bowker JH, nally published by Mosby-Year Book
neural pathways. The degree to which Pfeifer MA (eds): Levin and O'Nea/'s in 1992.)
fuJJ walking functio n can be restored The Diabetic Foot, ed 6. St. Louis, MO, 18. Mann RA, Poppen NK, O'Kinski M:
prosthetically o r or thoticaUy is rela- Mosby-Year Book, 2001, p 416. Amputa tion of the great toe: A clinical
tive to the loss of forefoot lever le1lgth 6. Pecoraro RE: The nonhealin g diabetic and b iochem ical study. Clin Ortlwp
and associated muscles. Reten tion of ulcer: A major cause for limb loss. 1988;226:192-205.
even the hindfoot, however, provid es Prog Clin Biol Res 1991;365:27-43. 19. Bowker JH, San Giovanni TP: Ampu-
for much greater independence and 7. Matos LA, Nunez AA: Enhancemen t of tation s and disarticulations, in Myer-
at ion energy conser vation than h igher lev- heal ing in selected problem wow1ds, son MS (ed): Foot and Ankle Disorders.
I am- in Kindwall EP (ed) : Hyperbaric Medi- Philadelphia, PA, WB Saunders, 2000,
els such as transtibial or transfemoral
·gery. cine Practice. Flagstaff, AZ, Best Pub- pp 466-503.
bsorb amputations. This is especially impor-
lishing, 1994, p 589. 20. Baumgartner R: Forefoot and hindfoot
t hree tant fo r elderly patien ts. In addition,
8. McCollum PT, Spence VA, Walker WF, ampu tations. Editions Scientifique et
amputation levels within the foot re-
et al: Oxygen-in duced changes in the Medicales Elsevier SAS (Paris) Surgical
sult in the least alteration of body im- Techniques in Orthopaedics and Trau-
skin as measured by transcutaneous
age, often requiring only shoe modifi- oximetry. Br J Surg I 986;73:882-885. matology. 55-700-C-lO, 2001, pp l -6.
[issue cations or a limited orthosis or 2 I. Kritter AE: A technique for salvage of
9. Sheffield PJ: Tissue oxygen measure-
)Und. prosthesis. m en ts, in Davis JC, Hu nt T K (eds): the infected diabetic foot. Orthop Clin
assist With convergent advances in Problem Wounds: The Role of Oxygen. NorthAnt 1973;4:21-30.
er urn wound healing, tissue oxygenation, New York, NY, Elsevier, 1988, p 17. 22. GerouJakos G, May ARL: Transmeta-
1e pa- and antibiotic thera py, as well as im - 10. Harward TRS, Volay R, Golbranson F, tarsal ampu tation in patients w ith
igram provements in vascular and ampu ta- et al: Oxygen inhalation: Induced peripheral vascular disease. Eur J Vas
,ound tion su rgery techniques, todays sur- transcuta neo us P02 changes as a pre- Surg 1991;5:655-658.
!asing geons have the opportunity to dictor of am putat io n level. J Vase Surg 23. Hobson Ml, Stonebridge PA, Clason
consider the foot rather than the tibia 1985;2 l :220-227. AE: Place of transmetatarsal a mputa-
ct of or fem ur as the site of election fo r 11. Wa tte! F, Mathieu D, Coget JM, et al: tions: A 5-year experience and review
amputations as a result of a variety of Hyperba ric oxygen in chronic vascular of the literature. J R Coll Surg Edinb
these
traumatic, ischemic, or infectio us wou11d manage ment. Angiology 1990; 1990;35:113- 115.
th the
conditions. 41:59-65. 24. Durham JR, McCoy OM, Sawchuck
:ice of
12. Karan fi lian RG, Lynch TG, ZiruJ VT, AP, et a l: Open transmetatarsal ampu-
llld is
et al: The value of laser-Doppler veli- tation iu the treatment of severe foo t
al, ad- infection. Am J Surg 1989; 158: 127-130.
comet ry and transcutaneo us oxygen
vaso- References tensio n deter mination in predicting 25. Pinzur MS, Ka mi nsky M, Sage R, et al:
td caf· healing of ischemic forefoot ulcer- Amp utations at the middle level of the
1. Bowker JH: Partial foot amp utations
serum ations and amputations i11 diabetics. foot. J Bone Joint Surg Am 1986;68:
and disarticulations. Foot Ankle Clin
diabe- North Am 1997;2:153. J Vase Surg 1986;5:51 -5161. 1061-1064.
,e lim- 13. Grayson Ml, Gibbons GW, Balogb K, 26. McKitt rick LS, McKittrick JB, Risley
2. Millstein SG, McCowan SA, Hunter
r1 ,and GA: Tra umatic partial foot amp uta - et al: Probing to bone in infected pedal TS: Transmetatarsal amputatio n for
,evated tions in ad uJts: A long-term review.. ulcers: A clinical sign of underlying in fectio n or gangr ene in patients with
king to I Bone Joint Surg Br 1988;70:251 -254. osteomyelitis in d iabetic patien ts. di abetes mellitus. Arm Surg 1949;130:
edema JAMA 1995;273:721-723. 826-935.
3. McCo Ll um PT, Walker MA: The choice
1e first between limb salvage and ampu tation: 14. Grodinsky M: A study of fascia! spaces 27. Lisfranc J: Nouvelle methode opera-
,e eval· Major limb am putation for end -stage of the feet. Surg Cynecol Obstet 1929; toi re po ur !'amputation du pied dans
closed 49:737-751. son ar ticulation tarsometatarsienne:
)earing

Methode precedee des nombreuses 32. Persson BM, Soderberg B: Pantalar 35. Oberg MS, Lindsey D: Editorial: Do
modifications qu'a subies celle de fusion for correc.tio n of painful equi- not put hydrogen peroxide or povi-
Chopart. Paris, France, Gabon, 1815. nus after traumatic Chopart's amputa- done iodine into wounds! Am JDis
28. Letts M, Pyper A: The modified tion: A report of 2 cases. Acta Orthop Child 1987;141:27-29.
Chopart's amputation. Clin Orthop Scand l 996;67:300-302. 36. Linea weaver W, Howard R, Soucy D,
l 990;256:44-49. 33. Bowker JH: The choice between limb et al: Topical a11ti.microbial toxicity.
salvage and amp utation: Infection, in Arch Surg 1985;120:267-270.
29. Marquardt E: D ie Chopart-
Bowker JI-I, M ichael JW (eds): Atlas of
Exartikulation mit Tenomyoplastik. 37. Sieggreen MY: Healing of physical
Limb Prosthetics: Surgical, Prosrhetic
Z Orthop 1973;111 :584-586. wounds. Nurs Clin North Am 1987;22:
and Rehabilitation Principles, ed 2.
30. Burgess EM: Prevention and correc- 439-447.
Rosemont, IL, American Academy of
tion of fixed equinus deformity in Orthopaedic Surgeons, 2002, pp 39- 38. Stotts NA, Washington DF: Nutrition:
mid-foot amputations. Bull Prosthet 43. (Originally published by Mosby- A critical component of wound heal-
Res 1966;10:45. Year Book in 1992.) ing. AACN Clin Grit Care Nurs
31. Menager D, Chiesa G, Ha Van G, 34 . Rodeheaver G, Bellamy W, Kody M, 1990;1:585-594.
Lefevre B, Camilleri A: Conuite a ten ir et al: Bacterial activity and toxicity of
devant une amputation de Chopart iodine-containing solutions in
traumatique. Med Chir Pied 1988;4:35. wounds. Arch Surg 1982;117: 181-186.
ln1
The
men
man
func
bion
amp
the
fonc
ple I
avail
also
rang
the 1
som,
tion:
clinj
deci:
pros
indi·
Bic
No1
The
plex
of-....
stoo
stric
load
tion
wan
thes,
anis:
the .I
T
gr01:
duri
lllitt

Amputations and Disarticulations
), Within the Foot: Prosthetic
Management
22: David N. Condie, CEng
Roy Bowers, SRProsOrth
on:
al-
Int roduction
The successful prosthetic manage- normal level walking, these loads are Internal rotation of the tibia com-
ment of partial foot amputations de- directed initially onto the heel, the mences during the swing phase and
mands a clear understanding of the specially adapted fatty tissues of continues after heel contact until the
functions of the normal foot and the which are ideally suited to the absorp- foo t is flat on the ground. During this
biomechanical consequences of each tion of the high forces generated a): phase, the foot pronates about the
amputation variant. Depending on impact and during the subsequent subtalar joint axis, thereby maintain-
the extent of the amputation, the loading of the limb. Once the foot is ing the normal toe-out position of the
functional problems range from sim- flat and until the heel leaves the foot. Elevation of the lateral margin
ple to severe. The range of currently ground as push-off is initiated, the of the foot, which is a consequence of
available prosthetic solutions may supporting forces are shared between hindfoot pronation, is counteracted
also be considered as a continuum the heel and the forefoot, with only a by supination of the forefoot, thus
ranging from very simple toe fillers to small contribution from the lateral ensuring that ground contact is
the more complex designs favored by aspect of the rnidfoot. This method of achieved across the entire forefoot.
some patients with Chopart amputa- load transmission is commonly at- After the foot is flat on the ground,
tions. Armed with this knowledge, the tributed to the arch structure of the the t ibia rotates externally and the
clinician cru1 then make appropriate foot, even though it is now clearly un- foot supinates about the subtalar joint
decisions regarding the materials and derstood that its effectiveness is a
axis to absorb this motion, thus pre-
prosthetic designs to be used for each function of a number of neuromus-
venting slippage occurring between
individual. cular mechanisms. Once the heel
the foot and the ground. The associ-
leaves the ground, the increased
ated elevation of the medial margin
ground force associated with push-off
Biomechanics is transmitted through the area de-
of the foot is counteracted by prona-
Normal Foot Function fined by the metatarsal beads and the tion of the forefoot, enabling the
pads of the toes. As body weight is maintenance of full forefoot loading.
The normal foot is an extremely com-
transferred to the contralateral limb, After the heel leaves the ground, the
plex structure, the detailed function
of which is still only partially under- this load reduces and localizes on the foot pronates, transferring the area of
stood. This discussion will be re- plantar surface of the hallux. support medially onto the first meta-
stricted to a brief consideration of the The functions of the joints of the tarsal head and then the hallux as the
load-bearing structure and the func- foot have been the subject of endless foot loses contact with the ground.
tion of the foot joints during normal investigation. The ability of the foot During the initial loading phase,
walking. Further information on to alter its shape and alignment is of the midtarsal joint acts in concert
these and the other ankle-foot mech- considerable importance in adapting with the subtalar joint. Thereafter, as
anisms may be obtained by consulting to variations in the slope of the walk- the subtalar joint supinates, the mid-
the relevant literature. 1• 4 ing surface. A more subtle but equally tarsal joint locks and stiffens the long
The foot is the means whereby the important role, however, concerns the arch of the foot to prepare it for the
ground-reaction forces generated absorption of the longitudinal rota- increased dorsiflexion moment that it
during physical activities are trans- tions of the lower limbs that occur is subjected to after the heel leaves the
mitted to the body structure. Dming with each stride (Figure 1). ground.

be lost following tarsometatarsal and head!~

transtarsal amputation. 9 • 13 the s
Heel contact Foot flat Heel rise Toe-off
metal
+ + + + is an1
I Prosthetic
plant
Tibial Rotation Assessment and an e:i<
Designs resist
External 1 (in tl:
Internal t Devices used in the management of
partial foot amputations are fre-
tive t
The
quently referred to as both prostheses reqm
I 50 Foot immobile
and orthoses; sometimes the term
"prosthosis" is used. Many of these
designs incorporate principles used in
foot orthoses or ankle-foot ortboses
cal is
lectio
these
of an
(AFOs), as well as those used in lower
s,,,,JJ!
Pronation
Subtalar Rotation limb prostheses. Shoe modifications
are also commonly provided to en-
hance fw1ction for these levels of loss;
Am1
The
the a1
therefore, a knowledge of pedorthic prim:
pri nciples is important. load-
As with all levels of amputation, creas,
assessment of a number of factors hea&
must precede prescription. The am- by tl
0 20 40 60 putee's control of the remaining symp
joints of the foot and ankle must be the I
Percent of walking cycle
assessed. The presence of muscle im- fun ct
balance and joint instability or defor- the l,
Figure 1 Longitudinal rotations of the leg and associated subtalar joint motions during mity, either fixed or correctable, meta
walking. should be noted. The tissue coverage mall}
at the amputation site and the sensi- for I
tivity and any adherence of the scar toes
should be assessed. Vascularity, sensa- lem,
tion, and the presence of neuropatby ru11n
Functional Loss After Similarly, any amputation proxj.
must be noted, and the foot should be itive
mal to the metatarsal heads removes
Amputation the contribution that these structw-es checked for callosities or other skin the le
The loss of normal foot function after lesions. The ability to comfortably C<
make to the normal mediolateral sta-
bear weight through the residual foot dress
amputation is progressively more se- bility of the foot. The natural shape of
and the amputee's balance should be puta1
vere the more proximal the site of the longitudinal arch of the foot re-
checked. The patient's aspirations ins ta
amputation. The extent of the loss sults in a residual foot with an appar-
wit!, regard to activity level and the defo,
may be summarized as relating to ently supinated forefoot, which if left
cosmetic appearance of the prosthesis may
three prin1ary aspects of foot func- untreated wiJJ inevitably result in pa tie
are of major importance and wiJJ help
tion: load-bearing capacity, stability, compensatory pronation of the hind- soft
influence the prescription process, be-
and dynamic function. foot. prost
cause higher levels of function are of·
Any partial foot amputation re- As the level of amputatjon moves inso,l
ten at the expense of cosmesis.
duces the forefoot load-bearing area, proximally, the active flexion of the sectic
The methods of compensation for
and any amputation proximal to the first metatarsophalangeal joint at final each of the more commonly encow1- the 1,
metatarsal heads totally eliminates push-off is eliminated, followed by tered amputation levels will be dis- this I
this load-bearing site. [ronically, the loss of the supinatory/pronatory ca- cussed in detail, but one important man1
magnitude of the forefoot ground- pability of the forefoot. Fortm1ately, if biomechanical issue should be men- the I
reaction force has been shown to in- the amputation surgery has been per- tioned here. When the surgery is con· trans
crease following partial foot amputa- formed according to the best current fined to the toes, prosthetic forefoot the
tion because of the reduced forefoot practice, both ankle and subtalar joint loading, which is most significant af- Pros1
lever arm when the patient attempts function most likely will be preserved, ter heel-off, may simply be trans· a pla
to walk in a normal manner. s-s although midtarsaJ joint function will ferred directly onto the metatarsal tions

Chap ter 35: Amputations and Disarticulations Within the Foot: Prosthetic Man agement 451
nd beads and any remaining toes. When

the surgery involves removal of the
metatarsal heads, however, this force
is anteriorly offset from the residual
plantar tissues. This action results in
an external moment that will, unless
resisted, cause the prosthesis to rotate
(in the direction of dorsiflexion) rela-
of tive to the residual foot (Figure 2).
fre- Figure 2 A, Amputation of t he toes:
The management of this particular ground-reaction force t ransferred directly Figure 3 Modif ied insole (inlay) with
:ses requirement is one of the most criti- onto metatarsal heads. 8, Amputation fi ller for amputation of t he t oes.
:rm cal issues to be considered in the se- proximal to t he metatarsal heads:
tese lection, manufacture, and fit of pros- ground-reaction force results in a dorsi-
i in flexion moment.
theses for these more proximal levels
>ses of amputation.
wer
ons Amputation of the Toes
en- The functional loss associated with
oss; the amputation of one or more toes is
thic primarily a reduction in the forefoot
load-bearing area, resulting in in-
ion, creased pressure on the metatarsal
:tors heads, which are also more exposed
am- by the removal of the toes. These
ning symptoms will be most pronounced if
:t be the hallux is removed, when foot
im- fu11ction also will be compromised by
!for- the loss of active flexion of the first A B
able, metatarsophalangeal joint, which nor-
:rage mally occurs at the end of push- off. Figure 4 A, Foot with amputation of one of the central t oes. 8, Toe spacer improves the
ensi- For normal walking, the loss of the alignment of the remaining toes.
scar toes is not a major fimctional prob-
:nsa- lem, but loss of the great toe makes
,athy rw111ing and participation in compet-
ld be itive sports more difficult because of
skin the loss of active push-off.
tably Cosmetic issues need to be ad-
I foot dressed. Most prostheses for toe am-
Id be putations consist of a toe filler to re-
1tions instate normal foot shape and prevent
d the deformation of the shoe, which also
thesis may be a cause of discomfort. Some
I help patients elect to pack the shoe with
:s, be- soft foam or cloth. Alternatively, the
re of- prosthesis may consist of a modified Figure 5 A, Amputation of t he second through fifth toes. 8, Silicone prosthesis in place.
insole (inlay) , with a built-up foam
m for section acting as a replacemen t for
the lost digits (Figure 3). If required, distribute pressure away from this model of the foot is not generally re-
coun-
e dis- this foam section may be formed in a area and onto the medial longitudinal quired for fabrication of the prosthe-
ortant manner that resists any tendency of and transverse metatarsal arches, resis.
men- the remaining toes to deviate in the sulting in improvements in comfort Silicone replacement of the toes
s con- transverse plane. In contrast, when and gait. offers optimum cosmesis (Figure 5),
refoot the hallux has been removed, the The provision of a toe spacer may but this highly specialized technique
int af- prosthesis is best custom fabricated to be beneficial in patients where one of may be unavailable at some prosthetic
trans- a plaster model of the foot. Modifica- the central toes has been removed facilities, and specialist mam1facturers
atarsal tions at the amputation site re- (Figure 4). For these designs, a plaster may need to be consulted. The psy-

Figu1
Figure 6 A, Ray amputation of the right foot. B, Silicone prosthesis in place. hing
Figure 7 Forces occurring between the
donr
residual foot and the socket of a trans-
chological benefits of a foot that ap- pressure-sensitive material next to the metatarsal amputation prosthesis at
skin, reinforced with a firmer, more push-off. F1 = force at plantar surface of
pears normal when wearing open sity
the residua l foot; F2 = force at dorsal sur-
shoes or sandals can be very signifi- durable base layer, which will improve face of the residua l foot; R = ground- rato
cant and should not be underesti- both its function and longevity. The reaction force; W = body weight. the
mated. prosthesis is built up to reinstate nor- sod
Any tendency of the shoe to de- mal foot shape, thus restoring me- don
form may be resisted by reinforcing diolateral stability and indirectly fa- surface of the longitudinal arch of the
the
the sole with a steel plate or a foot- cilitating subtalar joint function. foot both as a load-bearing area (Fl)
eith
plate composed of a carbon compos- Silicone prostheses combine these and to restore mediolateral stability.
the:
ite material; however, this material functions with excellent cosmetic res- However, for this mechanism to be ef-
app
should not be too rigid, or normal toration (Figure 6). fective, it will be necessaq for the
to I
foot "third rocker" will be inhibited. 11 If necessary, mediolateral stability prosthetic socket to generate a poste-
in t
When further pressure reduction is may be further enhanced by wedging riorly directed force (F2) on the dor-
required at the amputation site, a the prosthesis itself, or by the addi- sum of the residual foot (Figure 7).
sho
rocker sole with its apex behind the tion of either a wedge or flare to the This same force generates a moment
am
metatarsal heads may be added to the shoe. The use of a prosthesis will pre- that resists the tendency of the pros-
the
shoe. vent deformation of the shoe and may thesis to rotate (in the direction of
efff
remove the need for split size or dorsitlexion) relative to the residual
ten
Ray Amputations custom-made footwear. foot when weight is applied to the
the
The functional consequences of am- prosthetic forefoot.
Transmetat arsal enc
putation of one or more rays of the Some designs of prostheses for this
foot depend on the position and ex- Amputation level are similar to the molded insole Ta
tent of the tissues removed. In every The functional loss that occurs when type used for toe amputations, func-
Tr,
instance, there vvill be a reductiou in the amputation procedure involves ·t ioning as forefoot fillers maintained
in correct relation to the residual foo t lnE
the forefoot load-bearing area, result- the removal of the metatarsal heads is
by the patient's shoe. Better results ass
ing in increased pressure on the re- substantially greater than in toe am-
can be achieved by custom fabrication pn
maining forefoot plantar tissues, putations. In these amputations, the
to a plaster model, which has been w]'.
which may be a problem for insensate entire normal forefoot load-bearing
carefully shaped so as to transfer the me
patients or patients with diabetes capacity is eliminated. In addition,
forefoot ground-reaction force be- SOJ
mellitus. If the amputation includes forefoot mediolateral stability will be
either the first or fifth rays, either sin- hind the cut bone ends. If correctable, tio
impaired, which may result in prona-
gly or with adjacent rays, there is an the arches of the foot should be rein- mi
tion of the hindfoot. Finally, forefoot
associated loss of mediolateral foot stated, and this is best done during pa
supination and pronation are largely
stability affecting the patient's bal- eliminated. casting. If the arches are not correct- tic
ance. Additionally, supination and pro- The removal of the metatarsal able, the prosthesis must accommo-
nation of the forefoot will be virtually heads means that it is no longer prac- date and support them to prevent fLrr- pr
eliminated. tical to transfer the forefoot ground- ther deformation. re:
The stability of the prosthesis on A preferred option is to construct a SU
reaction force (R) directly onto the
the residual foot requires intimacy of plantar surface of the residual foot; prosthesis with a molded or lami- in
fit. It therefore typically takes the therefore, the rotational stability of nated socket, built up to replace the m
form of an insole that is custom- the patient/prosthesis interface will lost forefoot, including a soft liner or
molded to a plaster model of the re- require special attention. Attempts anterior pad if required. 14 This pros- p1
sidual foot, consisting of a soft, should be made to use the remaining thesis resembles a modifi~d Un iver- w

Chapter 35: Amputations and Disarticulations Within the Foot: Prosthetic Management 453
Area of force application

Figure 8 Transmetatarsal prosthesis w ith
hinged laminated socket to facilitate Figure 9 Loading the sustentaculum tali Figure 10 Tarsometatarsal and transtar-
1 the donning. to resist pronation of the hindfoot.
trans- sal amputation prostheses/perimalleolar
is at designs. Forces occurring between the re·
sidual foot and the socket at push-off.
ice of sity of California Biomecbanics Labo- amputations, can result in retention F1 = force at plantar surface of residua l
al sur-
ound- ratory (UCBL) foot orthosis, covering of a useful degree of ankle and even foot; F2 = force at calcaneus; R = ground-
the dorsum of the foot. The plastic subtalar joint function. Conversely, reaction force; W = body weight.
socket may be hinged to facilitate when this is not the case, the unre-
donning (Figure 8). The tendency of sisted action of the intact calf muscles
of the the foot to pronate can be addressed will inevitably produce a deformed
t (Fl)
either by medially wedging the pros- equinovarus position of the residual
bility. thesis to support the forefoot or by foot over tin1e.
beef- The designs of prostheses that have
applying a pronation-resisting force
,r the been produced for these amputation
to the area of the sustentaculum tali
poste-
in the socket15 (Figure 9). levels are categorized as perimalleolar
e dor- and high-profile designs. Perimalle-
The addition of a rocker sole to the
lre 7). olar designs include inframalleolar
shoe, with its apex proximal to the
oment designs, where the proximal trimline
amputation site, can further relieve
pros- is below the malleoli, and supramalle-
the cut bone ends. This also has the Figure 11 Tarsometatarsal and transtar-
Lon of olar designs, where the proximal
effect of reducing the moment that sal amputation prostheses/high-profile
isidual trimline encloses the maUeoli. The designs. Forces occurring between the re·
tends to cause rotation of the pros-
to the choice of which category and which sidual foot and the socket at push-off.
thesis relative to the residual foot at
variant within that category to em- Fl = force at plantar surface of residual
end-stance. foot; F2 = anterior force at socket brim;
'or this ploy will depend on a number of fac-
insole F3 = posterior force at heel level; F4 =ob-
Tarsometatarsal and tors that will be discussed later. First, lique force created by combination of
, func- however, it is important to fully un- Fl and F3; R = ground-reaction force;
Transtarsal Amputations
1tained derstand the biomechanical basis on W = body weight.
1al foot Inevitably, the functional loss and the which each category functions.
results associated demands for successful 1n perimalleolar designs, it is ap-
ication prosthetic management are greatest propriate to attempt to use the resid- result, the socket will tend to rotate
s been when the surgery entails complete re- ual plantar surface of the hindfoot relative to the residual foot.
,fer the moval of all the metatarsals (tar- (Fl) to replace the support normally An alternative biomechanical solu-
ce be- sometatarsal or Lisfranc's amputa- provided by the absent forefoot be- tion to this problem, which was de-
ectable, tion) or amputation through the tween heel-off and toe-off. As with scribed as early as 1955, is to shape
)e rein- mid tarsal joint (transtarsal or Cho- transmetatarsal amputations, achiev- the socket so that it grasps the calca-
during part's amputation). All of the func- ing this goal requires the prosthetic neus firmly medjolaterally. 16 As the
:orrect· tional limitations described for trans- socket to generate a posteriorly di- socket attempts to "dorsiflex;' this ac-
ommo- metatarsal amputation wiU be rected force on the dorsum of the re- tion is resisted by downward forces
ent fur- present. In addition, the shape of ·the sidual foot. Unfortunately, because of (F2) generated on both sides of the
residual foot and the much-redluced its more restricted area of application calcaneus (Figure 10).
.struct a surface area available make the task of and its much shorter lever arm, this High-profile designs of prostheses
r lami- interfacing a prosthesis to it even force is not capable of successfuUy re- for these an1putation levels solve this
lace the more challenging. sisting the dorsiflexing moment cre- problem in an entirely different and
liner or As mentioned earlier, use of ap- ated by the prosthetic forefoot generally more satisfactory manner.
1is pros- propriate surgical procedures, even ground-reaction force (R) if the pa- In these designs, the forefoot dorsi-
Univer- with these most proximal partial foot tient attempts to walk normally. As a flexion moment is resisted by a force

quire<
forcec
socke·
Pigm<
closel
the i
color
fittin{
enoui
bepu
Figure 12 Slipper-type elastomer pros- brical
t hesis (STEP). Figure 14 Lange silicone prosthesis. Tb
user
Figure 13 Imler prosthesis. facto1
on a
couple created by socket interface eral factors, including the functional some
forces located anteriorly at the socket also may be beneficial. NaturaUy, for Then
and cosmetic aspirations of the am-
brim (F2) and posteriorly at heel level slipper designs to be successful, the perirr
putee, the presence of joint instability
(F3) . This latter force combiJ1es with amputee must be able to tolerate full activ~
or deformfry, the ability to tolerate
plantar surface weight bearing. groUI
the plantar support force (Fl ) to cre- ful l body weight, and the sensitivity of
The major shortcomings of peri- achie
ate a single, oblique force (F4) . Obvi- the amputation site.
ously, the higher the trirnline and
malleolar designs are related to sus- a rec
Perimalleo/ar Designs pension problems, d iscomfort at the cl earl
hence the wider the separation be-
anterior aspect of the residual foot at ers o l
tween F2 and F3, the lower will be Many popular modern designs of
end-stance, and inability to generate succe
their magnitude and consequently t he prostheses for these amputation levels
adequate p ush-off, all of which limit these
pressure on the residua] foot at their terminate around the level of the an-
the activity level of the user. Some of
sites of application (Figure 11). kle joint. InframalleolaT designs of Higl
these shortcomings may be overcome
One final biomechanical consider- prostheses are unobtrusive and com-
by providing a prosthesis in the form The ,
ation must be mentioned before dis- bine reasonable function and good
of a bootie that encloses more of the stanc
cussing prescription criteria and re- comfort with very satisfactory cosme-
residual foot, with a corresponding the c
lated design issues. Irrespective of sis. They permit the amputee to make
reduction in contact pressure. The an ale
which category of device is supplied, use of the talocrural and subtalar
stability of the prosthesis on the re- non:a
if the user attempts to simulate nor- joints, but it should b e noted that this sidua] foot also is improved, as is sus- flexo
mal push-off, requiring the genera- is appropriate only in patients in fully
pension. A ni1mber of designs with
tion of a significant forefoot ground- whom there is no requirement for sig- these
varying degrees of flexibility have
reaction force, the construction of the nificant joint realignment, restriction been used successfully and combine (Figt
device must be stiff enough to with- of motion, or augmentation of func- reasonable levels of function and cos- ate s
stand the resulting dorsiflexion motion 17 (Figure 12). If necessar y, minor mesis (Figures 13 and 14). Some of vent
ment without deforming. realignment of the subtalar joint can these prostheses are fitted with zip or kle ,
In most respects, the si milarities be achieved by appropriate wedging Velcro closures to facilitate don- impc
between tarsometatarsal and transtar- of the prosthesis or by wedging or ning. 1s, 19 quin
saJ amputations mean that they can flaring the shoe. OriginaUy introduced for their ex- ante1
be considered together. ln both cases, In aU perimalieolar designs, resis- ceUen t cosmetic appearance, silicone fore,
if control of the talocrural or subtalar tance to the end-stance dorsiflexion prostheses (Figure 15) have proved ante1
joints is impaired and results in de- moment is achieved by the intimacy particularly successful for amputees ism
formity, this m ust be addressed when- of the socket fit over the anterior/ with adherent or fragile scar tissue. In rior
ever possible by realigning these dorsal aspect of the residual foot and, addition, they permit successful resto· 17).
joints during the casting procedure importantly, by the firm grip on ei- ration of balance and a more normal proa
and with further modification of the ther side of the calcaneus. Skillful gait when appropriately reinforced to to b
positive cast. If mobile, the heel pad modification of a plaster model of the achieve the degree of rigidity required crest
must be stabilized in the correct posi- foot is an important factor in achiev- to match the amputee's functional mod
tion to avoid medial deviation. ing success. The use of soft interface needs. 20 As a general rule, greater ri- Ieng
A n umber of prosthetic designs are padding, or silicone or polyurethane gidity is indicated for the more active carb
available for these amputation levels, liners, which have excellent pressure user. A lost wax method is used to With
and prescription will depend on sev- and shear management p roperties, create a negative impression of the re- sirec

quired foot shape, and pure rein-

forced silicone is used to form the
socket and the foot simultaneously.
Pigment is added to the silicone to
closely match the basic tiss ue color of
the individual, with more detailed
color matching done at the time of
fitting. These sockets may be flexible
enough to allow the residual foot to
be p ushed into the prosthesis after lu-
brication with skin lotion.
The anticipated activity level of the
user is perhaps the most important
factor to be considered when deciding Figure 15 Silicone prosthesis by M . Alaric, Paris. (Reproduced with permission from
Soderberg B, Wykman A, Schaarschuch R, Persson BM: Silicone prosthesis, in Partial Foot
on a suitable prescription fo r the itar- Amputations: Guidelines to Prosthetic and Surgical Management. Helsingborg, Sweden,
sometatarsaJ or transtarsal amputee. AB Bok tryck, 2001, pp 80-85.)
for There is no scientific evidence that
he perimalleolar designs allow the more
ull active user to generate the forefoot
ground-reaction force necessary to
:n- achieve normal push-off. In contrast,
clS- a recently published Swedish study
the clearly demonstrates the ability of us-
at ers of a modern high-profile desigl!l to
ate successfully generate and transmit
1
nit these forces to their residual foot.2
of
me High-Profile Designs
rm The absence of push -off at the end of
the stance phase seriously compromises
ing the quality of gait. This situation is
['be analogous to the problem faced by
re- nonamputees with inadequate p laJI1tar
us- flexor strength, who are often success-
rith fully treated with a rigid AFO. Pros-
Figure 17 High-profile design prosthesis
ave theses based on a rigid AFO design
with anterior tibial shell and footplat e of
,ine (Figure 16), albeit with an appropri- carbon f iber. (Reproduced with permis-
:os- ate sole plate and forefoot filler, pre- sion from Soderberg 8, Wykman A,
Figure 16 Prosthesis based on a modified
of vent dorsiflexion by blocking the an- AFO. (Reproduced with permission from
Schaarschuch R, Persson BM: The chopart
23
> or kle at an appropriate angle. 22 • An Stills ML: Partial foot prostheseslorthoses.
amputation, in Partial Foot Amputations:
Guidelines t o Prosthetic and Surgical
on- important socket interface force re- Clin Prosthet Orthot 1988;12:14-18.)
Techniques. Helsingborg, Sweden, AB
quired to resist dorsiflexion is located Boktryck, 2001, pp 51-59.)
ex- anteriorly at the socket brim. There-
one fore, a prosthesis constructed with an
ved anterior shell and a posterior opening T he angle at which the ankle is for a rocker sole on the footwear,
tees is more appropriate than the poste- aligned is important. An anterior tib- which otherwise m ight be required,
:. In rior shell AFO-type designs (Figure ial tilt of 5° to 10° is desirable if a and might still be required if the de-
sto- 17). Naturally, this anterior shell ap- smooth rollover in late stance is to be sired angle of dorsiflexion cannot be
mal proach will require the plaster model achieved.2 4 It is the anterior tilt angle achieved. If necessary, a wedge
:l to to be modified to protect the tibial of the tibia relative to the floor that is build-up under the heel may be in-
ired crest and the amputation site. Some corporated to accommodate any equi-
important, rather than the true angle
)Dal modern designs incorporate a full. nus deformity (Figure 18, B). If the
of the talocrural joint, because the
: n- length energy-storing footplate of
heel height of the footwear always wedge is made from a compressible
:tive carbon composite material, built up
must be considered (Figure 18.., A) . material, plantar flexion will be simu-
i to with a foam material to create the de-
This alignment should avoid the need lated in a manner similar to the solid
: re- sired foot shape.2 1

A B References 15. (
dl1
I . Condie ON: Biomechanics, in Helal B,
SL
Rowley DI, Crachiollo A, Myerson MS 3(
(eds): Surgery of Disorders of the Foot
and Ankle. London, England, Martin 16. N
Dunitz, 1996, PP, 37-46. T
2. Wright DG, Desai ME, Henderson BS: si
4,
Action of the subtalar and ankle-joint
complex during the stance phase of 17. C
walking. J Bone Joint Surg Am 1964;46: p
361-382. B
Figure 18 Preferred anterior t ilt angle of 3. Elftman H: The transverse tarsal joint A
5° to 10°. A, Normally achieved by ankle and its control. Clin Orthop 1960;16: c
dorsiflexion. B, A heel wedge is requi red 41-45. ti
in the presence of an equinus deformity. Figure 19 Prosthesis based on a jointed
high-profile design permits plantar f lex- 4. Levens AS, Inman VT, Blosser JA:
ion w hile blocking dorsiflexion at an ap- Transverse rotations of the segments
ankle-cushion heel (SACH) pros- propriate angle. (Reproduced with per- of the lower limb in locomotion.
mission from Soderberg 8, Wykman A, J Bone Joint Surg Am 1948;30:859-872.
thetic foot. However, when an accom- Schaarschuch R, Persson BM: Evalua tion
modation for equiJ1US is necessary, 5. Chrza11 JS, Giurini JM, Hurchik JM: A
of different prosthetic solutions for Lis-
the length of the prosthesis will be in- biomechan ical model for the tralls-
franc amputees, in Partial Foot Amputa-
tions: Guidelines to Prosthetic and Surgi- metatarsal amputation. JAm Podiatr
creased, requiring a compensatory lift
cal Management. Helsingborg, Sweden, Med Assoc 1993;83:82-86.
on the contralateral side.
AB Boktryck, 2001, pp 76-79.) 6. Kavanagh PR, Ulbrecht JS, Wu G, et al:
Excessive toe-in of this style of
The diabetic foot with partial amputa-
prosthesis can lead to the development
tion: A biornechanical study. J Biomech
of a varus moment at the knee. There- 1994;27:606.
fore, it is important to ensure that the the residual foot and the presence of a
7. Boyd LA, Rao SS, Burnfield JM, et al:
forefoot section of the prosthesis is fixed equinovarus deformity makes
Forefoot rocker mechanics in individ-
formed so that its rotational align- distal weight bearing impractical. In uals with partial foot amputation. Gait
ment matches the sound side. It also these situations, a prosthesis employ- Posture 1999;9:144.
has been suggested that making the ing proximal weight-bearing tech- 8. Kelly VE, Mueller MJ, Sinacore DR:
soleplate stiffer on the lateral side will niques similar to those seen in trans- Timing of peak plantar pressure dur-
help resist this varus knee moment. 2 1 tibial prostheses is indicated.23 •25 1n ing the stance phase of walking: A
The use of a rigid high-profile de- general, patients who perform at study of patients with diabetes melli-
sign wilJ sacrifice all movement about higher activity levels will derive bene- tus and transmetatarsal amputation.
the remaining joints of the foot and J Am Podiatr Med Assoc 2000;90: 18-23.
fit from the provision of prostheses
ankle; however, because these move- 9. Parziale JR, Hahn KK: Functional con-
with higher trimlines.
ments are often reduced or absent, siderations in partial foot amputation.
this may not represent a serious loss. Ortl10p Rev 1988; 17:262-266.
In any case, the loss of these move- Summary 10. Letts M, Pyper A: The modified Cho-
m ents may be worthwhile to achieve part amputation. Clin Orthop 1990;
A comfortable socket, a balanced foot, 256:44-49.
improvements in comfort and gait.
and an optimal gait pattern are the 11. Wagner FW: Partial foot amputations:
SACH modification to the heel of the
c(jnical objectives for all users of par- Surgical procedures, in Bowker JH,
footwear will improve shock attenua-
tial foot prostheses. T he choice of the Michael 'fW (eds): Atlas of Limb Pros-
tion in early stance and sinrnlate
particular design to be used will de- thetics. Rosemont, IL, American Acad-
plantar flexion, but careful selection
pend on a number of fac tors and re- emy of Orthopaedic Surgeons, 2002,
of footwear with a compressible heel, pp 389-402. (Originally published by
eg, a sports shoe, may make this mod- quires a careful assessment of the user
Mosby-Year Book, 1992.)
ification unnecessary. A more sophis- and a full appreciation of the individ-
12. Moore JW: Prostheses orthoses and
ticated approach is to in corporate an ual's aspirations. New materials ru1d
shoes for partial foot amputees. Clin
ankle joint in the prosthesis that per- fabrication techniques have permitted
Podiatr Med Surg 1997;14:775-784.
mits plantar flexion but blocks dorsi- the development of both cosmetically
13. Perry J: Gait Analysis: Normal and
flexion at the appropriate angle, thus and functionally improved designs Pathological Function. Thorofare, NJ,
permitting more normal ankle joint that may make partial foot amputa- Slack, 1992.
motion (Figure 19). tion a practical alternative to higher 14. Collins SN: A partial foot prosthesis
In some cases, th e combination of amputation where the pathology perfor the transrnetatarsal level. Clin
a very small plantar surface area of mits. Prosthet Orthot 1988; 12:19-23.

15. Colson JM, Berglund G: An effective 18. Imler CD: Imler Partial Foot Prosthe- 22. Sti.Us ML: Partial foot prostheses/
design for con trolling the unstable sis: IPFP- The Chicago boot. Ort/10t orthoses. Clin Prosthet Orthot 1988;
B, subtalar joint. Orthot Prosthet 1979;33: Prosthet 1985;39:53-56. 12:14-18.
AS 39-49. 19. Lange LR: The Lange silicone partial 23. Rubi.n G, Cohen E: lndications for
16. MacDonald A: Chopart amputation: foot prosthesis. J Prosthet Orthot 1991; variants of the partial foot prosthesis.
The advantages of a modified prosthe- 4:56-61. Orthop Rev 1985;14:49-56.
sis. J Bone Joint Surg Br 1955;37: 20. Kulkarni J, Curran B, Ebdon-Parry M, 24. Glancy J, Lindseth RE: The polypropy-
!S: Harrison D: Total contact silicone par-
468-470. lene solid-ankle orthosis. Orthot
nt tial foot prostheses for partial foot
J7. CbjJds C, Staats T: The slipper type Prosthet 1972;26: 14-26.
amputations. Foot 1995;5:32-35.
16: partial foot prosthesis, i.n Advanced 25. Cohen-Sobel E, Caselli MA, Rizzuto J:
Below-knee Prosthetic Seminar. Los 2 l. Soderberg B, Wykman A, Schaars-
Prosthetic management of a Chopart
chuch R, Persson BM: Partial Foot Am-
.n t Angeles, CA, UCLA Prosthetics and variant. J Am Podiatr Med Assoc
putation. Helsingborg, Sweden, Swed-
i: Orthotic Education Program, Fabrica- l 994;84:505-51o.
ish Orthopaedic Association
tion Manual, 1983.
Publications, 200 I .
ts
72.
:A
:t al:
llta-
iech
al:
rid-
Gait
LU-
lli-
,n.
-23.
con-
tion.
ho-
);
.ons:
l,
'05·
cad-
02,
I by
1d
:lin
L
NJ,
:sis

Ankle Disarticulation and
Variants: Surgical Management
John H. Bowker, MD
Introduction
In 1843, James Syme, then Professor amputation and requires minimal tial to maintain this position because
of Surgery at the University of Edin- prosthetic ga it training, chiefly the calf atrophy inevitably occurs. The
burgh, described his innovative oper- equalization of stride length and time main limitation of the procedure is
ation, now known as the Syme ankle in stance phase. From the patient's cosmetic; it results in distal buJkiness
disarticulation, as "disarticuJation viewpoint, a Syme ankle disarticula- of the rnalleoli and heel pad that is re-
through the ankle joint with preservation is a less destructive procedure flected to a variable degree in the
tion of the heel flap to permit weigbt- than a trnnstibial amputation.2 The prosthetic socket, dependi ng on the
bearing on the end of the stump. L Be- heel pad is remarkably activity toler- surgical technique selected. Despite
cause the procedure preserves weight ant, even if insensate, as in many pa- this disadvantage, the benefit to the
bearing on the heel pad along normal tients with diabetes mellitus, provided patient of being able to comfortably
proprioceptive pathways, gait with a the heel pad is held directly under the engage in a wide range of activities
Syme ankle disarticulation is more tibia by an intimately fitted socket. suggests that much more frequent use
energy efficient than with a transtibial Careful prosthetic follow-up is essen- of this procedure is indicated.
B c
Figure 1 A 32-year-old man sustained work-relat ed t rauma to his left foot. A, Medial view of the foot showing loss of skin proximal to
the site of a standard Syme incision. B, Anterior view showing sufficient lat eral skin to compensate fo r lack of medial skin. C, Anterior
view 3 years after Syme procedure. The individual works, stands, and walks up to 16 to 18 hours daily without difficulty. (Reproduced
with permission from Bowker JH, San Giovanni TP: Amputations and disarticulations, in Myerson MS (ed): Foot and Ankle Disorders.
Philadelphia, PA, WB Saunders, 2000.)

occur
dures
the h
6). A
vere
prog1
with
tudit!
tial
tibia,
cienc
from
B c care
and J
Figure 2 A 32-year-old woman with type 1 diabetes mellitus was seen 1 year after sustaining a nondisplaced bimalleolar fracture of
the left ankle that was treated in a cast for 6 weeks. Loss of protective sensation to the level of the tibial tubercle was undetected by
the surgeon. A, Anterior view of the foot showing medial displacement. B, Use of an ankle-foot orthosis to attempt control of this
irreducible and increasing deformity caused a pressure ulcer over the lateral malleolus. C, AP radiograph shows dissolution of the ankle
Inc
joint, talus, and subtalar joint with varus deformity. (Reproduced with permission from Bowker JH, San Giovanni TP: Amputations and The
disarticulations, in Myerson MS (ed): Foot and Ankle Disorders. Philadelphia, PA, WB Saunders, 2000.)
disar
uisitt:,
thro-
w hie
canr
ca tic
too,
fran,
SUS<
ticul
WOU
lo ca
Figure 3 Right foot of a 66-year-old man seco
with diabetes mellitus with dry gangrene dun
of the distal forefoot. The posterior tibial witl
artery was patent, making the patient a wall
good candidate for a Syme ankle disartic- adv,
ulation.
bee,
vide
Patient Selection tole
bea1
Ankle clisarticulation with preserva-
am1
tion of the heel pad is suitable for B
treating several conditions. One ex-
ample is severe forefoot trauma that Figure 4 The left foot of a 41-year-old man sustained a crush injury of the forefoot by Cc
fork lift truck. The hindfoot was spared, permitting ankle disarticulation. A, Dorsal view.
spares the heel pad but leaves insuffi- B, Plantar view. (Reproduced with permission from Bowker JH, San Giovanni TP: Ampu- Abs
cient soft tissue to dose a midtarsal tations and disarticulations, in Myerson MS (ed): Foot and Ankle Disorders. Philadelphia, ank
(Chopart) disarticulation (Figure 1). PA, WB Saunders, 2000.) qua
The procedure is also a reasonable the
choice in selected cases of severe dia- forefoot due to occlusion of the distal staged procedure if infection is too witl
betic neuroarthropathy of the hind- arterial arch of the foot from periph- close to the heel pad to risk primary ma1
foot and/or ankle joint (Figme 2) . It eral vascular disease (Figure 3) or closure (Figme 5) . A much less com· COll
offers a more rapid return to weight- with severe crush injuries if the poste- mon condition for which the Syme ica1
bearing status than does ankle/ rior tibial artery is patent (Figure 4). procedure is sometimes appropriate is pla,
subtalar arthrodesis because it re- With wet gangrene of the forefoot, congenital arteriovenous fistulae of Wej
quires no fusion or fibrous ankylosis common in patients with diabetes the foot resulting i.n marked over- in .
of the involved bones. It can also be mellitus, Syme ankle clisarticulation is growth. With this condition, repeated adc
considered in dry gangrene of the useful, but care must be taken to do a hemorrhage from minor trauma may the

Chapter 36: Ankle Disarticulation and Variants: Surgical Management 461
occur despite embolization proce-

dures. In carefully selected patients,
the heel pad can be salvaged (Figure
6). Another unusual condition is se-
vere varus deformity associated with
progressive hemiatrophy. Cbildien
with unilateral or bilateral total longi-
tudinal deficiency of the fibula, par-
tial longitudinal deficiency of the
tibia, or partial longitudinal defi-
ciency of the femur may also benefit
from Syme ankle disarticulation with
care taken to preserve the distal tibial
and fibular physes 3' 4 (Figw·e 7).
·e of
,d by
'this Indications
inkle
;and The main indication for a Syme ankle
disarticulation is a foot with the req-
Figure 5 Extensive wet gangrene of t he Figure 6 Foot of a young woman several
uisite blood flow to the heel pad forefoot in a patient with diabetes melli- years after a Syme ankle disarticulation
through the posterior tibial artery in tus precluded even Chopart disarticula- performed for congenital arteriovenous
which a more distal functional level tion. Th e heel pad and posterior t ibial ar- fistu lae of t he foot. No new f istulae devel-
cannot be salvaged. A secondary indi- tery were intact, allowing a Syme oped, but resid ual distended veins are
cation is a midfoot infection that is procedure. seen extending to t he incision line on the
too close to the heel pad to risk a Lis- right.
franc (disarticulation between the tar-
sus and metatarsus) or Chopart disar-
ticulation. In such cases, the Syme
wound is left open initially to allow
local control of the infection before
secondary closure. The Syme proce-
dure is also a good choice for patients
with expectation of a high level of
walking activity. It is also particularly
advantageous for obese individuals
because the end-weight-bearing pro-
vided by a Syme procedure is better
tolerated than the peripheral weight-
bearing that results from a transtibial
amputation.
:,ot by Contraindications
I view.
11.mpu· Absolute contraindications to a Syme
~Jphia, ankle disarticulation include inade-
quate circulation to the heel pad via
the posterior tibial artery, infection
is too within the heel pad, and severe trau-
imary matic damage to the skin or fatty
com· compartments of the heel pad. Signif- Figure 7 Views of young boys w ith partial longitudinal deficiency of the left femur and
Syme icant tibial deformity may prevent t otal longit udinal deficiency of t he left fibu la. A, Preoperative view of one boy showing
:iate is placement of the heel pad in good limb-length discrepancy and equinus deformity. B, Postoperative view of another boy
lae of weight-bearing alignment, resulting fol lowing Syme ankle disarticulation showing the residual limb ready for prosthetic fit·
ting. (Reproduced with permission from Bowker JH, San Giovanni TP: Amputations and
over- in displacement of the heel pad. 2 In
disarticulations, in Myerson MS (ed): Foot and Ankle Disorders. Philadelphia, PA, WB
peated addition, some patients may object to Saunders, 2000.)
1a may the appearance of the residual limb

and the prosthesis; this m ust be antic- The absolute necessity of adequate tional status, as reflected in the serum
ipated and resolved before surgery. posterior tibial blood flow to the heel albumin level. Levels Jess than
Some surgeons have been reluctant to pad cannot be overemphasized. Dur- 3.0 g/dL can be indicative of starva-
recommend this procedure fo r young ing the 1960s, Sarmiento9 performed a tion, significant renal disease, acute
female patients, but Baumgartner5 series of Syme ankle disarticulations stress, or a combination of these fac-
and others believe that with appropri- in a group of 38 patients with forefoot tors. Patients who are immunosup-
ate preoperative counseling and mod- gangrene without regard to the pres- pressed as indicated by a total lym-
ern prosthetic techniques, the Syme ence of palpable pedal pulses; 19 phocyte count Jess than l,500/mm 3
procedure can be confidently recom- (50%) failed . The author also per- may also have decreased wound heal-
mended for this group. Because the formed the procedure on a second ing potential. Dickha ut and associ-
patient's cooperation is essential to group of 15 patients who were re- ates13 retrospectively reviewed Syme
both the short-term and long-term quired to have a palpable posterior healing rates in 23 patients with dia-
success of this procedure, the surgeon tibial pulse. Of these, 12 healed, for a betes who had adequate blood flow
should be aware that failure is likely failure rate of 20%. Francis and asso- and in whom serwn albumin levels
in a patient with a history of reckless ciates 10 reported that 19 of 22 patients and total lymphocyte counts had
(86%) with a palpable posterior tibial been obtained o n admission. Healing
noncompliance with medical advice Figur
pulse healed primarily. Laughlin and occurred in only 43% of those wit h a arter
or overt psychosis. In addition, pa-
Chan1bers 11 evaluated the predictive t ion
tients with end-stage renal dlsease serum albumin level less than
value of Doppler waveform configura- 3.5 g/dL and a total lymphocyte count ProfE
who require dialysis are unlikely to
tion in 52 patients with diabetes mel-
heal because of poor retention of se- less than l,500/mm 3 , in contrast with
litus before surgery. Of 29 patients, 26
rum proteins. 6 -8 (90%) with either a triphasic wave-
86% of those with higher values. Pin-
Relative contraindications include zur and associates8 concluded from a
form or a normal pulse healed, com-
problems that may be controllable, at similar study that a minin1um serum
pared with onl y 13 of 23 patients
least to some extent, by the treatment albumin level of 3.0 g/dL was suffi-
(57%) with a monophasic waveform.
team. Unless these conditions show cient. The dietary needs of the patient
If a patient with diabetes mellitus
some improvement preoperatively, with low serun1 albw11in levels can
presents with severe forefoot ischernia
they must be considered absolute usually be met by oral hyperalimenta-
or ischemic ulceration and has no dis-
contraindications. They include lym- tion. For patients with diabetes melli-
cernible posterior tibial pulse, consul-
phangitis ascending to the leg, low se- tation with a vascular surgeon may be tus, caloric increase must be matched
rum albumin due to malnutrition or indicated. Patients with diabetes typi- with appropriate increases in medica-
nephropathy, and congestive heart cally have occlusion of the posterior tion to prevent iatrogenic hyperglyce-
failw-e. tibial and peroneal arteries in the calf mia.
with retained patency of the vessels in Diffuse tissue glycation resulting
the foot. Angioplasty or bypass proce- from chronic hyperglycemia may have
Preoperative dures may improve distal flow suffi- a negative effect on wound healing as
Considerations ciently to allow healing distal to the well. The presence of chronic hyper-
Adequate Blood Flow transtibial level. Weaver and associ- glycemia can be inferred from re-
ates12 reported on 35 patients ranging peated glycohemoglobin levels in ex-
ln preparation for a Syme ankle disar- cess of 7%. Several studies have
in age from 40 to 77 years, of whom
ticulation, the surgeon must be cer- shown poor healing in hyperglycemic
31 (89%) had diabetes mellitus. A
tain that there is adequate perfusion rats, with wounds exhibiting de-
vascular procedure was performed in
of the heel pad, which occurs largely creased leukocytosis and impaired
22 patients with the most compro-
through the posterior tibial artery mised blood flow immediately before neovascularization as well as de-
(Figure 8). If a bounding posterior a Syme ankle disarticulation. Primary creased nitric acid synthesis, granula-
tibial pulse can be felt, no fmther in- healing occurred in 19 (86%), com- tion tissue mass, collagen content,
vestigation is needed. If a pulse can- pared with 77% in those in whom and wound strengtl1. 14- 17 Periopera-
not be felt, a portable Doppler device vascular intervention was deemed un- t ive control of very high senun glu-
may be used. This is, however, of lim- necessary. In another series of 13 pa- cose levels is therefore important, al-
ited use in patients with diabetes mel- Figu
tients who had vascular intervention though this may be difficult to
hoo
litus because artificially high values an average of 3 months before a Syme achieve if infection persists despite nea l
may be obtained from incompressible, procedure, 12 (92%) healed. 11 the use of antibiotics, indicating the Achi
heavily calcified arteries. In this case, need for prompt surgical manage- fron
or if edema is present, real-time flow Wound Healing Potential ment. Tight control of serum glucose miss
may be observed directly by means of Ami
Wound healing potential must also be levels should be delayed until the pa- son
duplex ultrasound angiography. assessed, including the patient's nutri- tient has recovered from the stress of ade,

um
han
·va-
:ute
fac-
up-
vm-
1m3
.eal-
oci-
yme
dia-
flow
:vels
had
Lling Figure 8 lateral view of a posterior tibial
ith a arteriogram showing its major contribu -
than tion t o heel pad circulation. (Courtesy of
Professor G. Neff.)
)Unt Figure 10 Syme procedure. A bone hook
Figure 9 Syme procedure. Medial view of
with a right foot showing the transverse inci· has been placed in the talar dome to pro-
Pin- sion line across the ankle joint, continu- vide anteroplantar traction on the foot.
>ma ing as a stirrup incision anterior to the Note the flexor hallucis long us tendon just
heel pad. The necrotic toes have been posterior to the talus, clearly demarcating
:rum
wrapped to exclude them from the sur- the safe area lateral to the medial neu-
uffi. gical field. (Reproduced with permission rovascular structures. (Reproduced with
tient from Bowker JH, San Giovanni TP: Am· permission from Bowker JH, San Giovanni
can putations and disarticulations, in Myer- TP: Amputations and disarticulations, in
:nta- son MS (ed): Foot and Ankle Disorders. Myerson MS (ed): Foot and Ankle Disorders.
Philadelphia, PA, WB Saunders, 2000.) Philadelphia, PA, WB Saunders, 2000.)
1elli-
ched
clica-
;lyce-
1lting
have
ng as
yper-
1 re·
n ex·
have
:emic
de·
,aired
de-
.nula-
11tent,
,pera· Figure 13 Syme procedure. Prior to clo·
1 glu· sure, flap lengths are carefully checked. If
the f it is too loose, skin is removed from
1t, al-
Figure 11 Syme procedure. The bone Figure 12 Syme procedure. Shortening the proximal flap . If too tight, the tibia
lt to will need to be appropriately shortened,
hook has been transferred to the calca- and narrowing of the malleoli is accom-
espite neal tuberosity to put tension on the plished easily with a sharp osteotome. which is accomplished most accurately
ig the Achilles tendon to facilitate its separation (Reproduced with perm1ss1on from with a broad saw. (Reproduced with per-
rnage· from the calcaneus. (Reproduced with per- Bowker JH, San Giovanni TP: Amputa- mission from Bowker JH, San Giovanni
mission from Bowker JH, San Giovanni TP: tions and disarticulations, in Myerson MS TP: Amputations and disarticulations, in
lucose Myerson MS (ed): Foot and Ankle Disor-
Amputations and disarticulations, in Myer- (ed): Foot and Ankle Disorders. Philadel-
1e pa· son MS (ed): Foot and Ankle Disorders. Phil- phia, PA, WB Saunders, 2000.) ders. Philadelphia, PA, WB Saunders,
:ess of adelphia, PA, WB Saunders, 2000.) 2000.)

464 Section TIJ: The Lower Limb
surgery, to avoid life-threatening ia- sensory nerves to avoid their entrap- avoid growth of painful bony masses.
trogenic hypoglycemia. ment in the incisional scar. These in- Provision of a durable and com-
clude the branches of the superficial fortable weight-bearing surface is the
Infection Control peroneal nerve and the deep peroneal next concern. Harris21 recommended
A major preoperative management nerve, which must be separated from removing a 1-cm slice of the distal
goal for any forefoot or midfoot in- its accompanying vessels and short- tibia, effectively removing the malle-
fection is prevention of the proximal ened. oli. This is best done with a wide-
spread of infective material along tis- Following incision of the anterior blade saw to ensure that the distal tib-
sue planes. The fast measure required ankle capsule, the foot can be plantar ial smface is parallel to the floor
is prohibition of all further weight flexed witll the aid of a large bone during weight bearing. Sarmiento9
bearing; the second is prompt initial hook inserted in to the talar dome advised removing 1.2 cm of the distal
drainage of any abscess in the emer- (Figure 10). Alternatively, as sug- tibia and narrowing tlle malleoli to fit
gency department if an operating gested by Oznur, 22 a Steinmann pin a more cosmetic prosthesis with an
suite is not available soon after medi- can be placed transversely in the pos- expandable liner. Wagner6 also modi-
cal clearance. Decompressive inci- terior talus and attached to a traction fied tlle traditional technique used in
sions must respect the heel pad if a bow or Ilizarov half ring with traction
patients witll diabetes mellitus by
Syme ankle disarticulation is to re- on tlle talus applied through a cord A
shortening and narrowing the malle-
main feasible. Deep wow1d cultures, attached to weights or the surgeon's
ol i but leaving the cartilage of the
both aerobic and anaerobic, should be foot. Care must be taken to pass the
plafond intact (Figure 12). He also
obtained and broad-spectrwn antibi- pin from medial to lateral to avoid
recommended that the procedure be
otics begun because most diabetic damage to the posterior tibial artery.
done in two stages in cases of forefoot
foot infections are polymicrobial. The Traction will assist in locating tlle ten-
infection to reduce the theoretic
antibiotics administered initially, don of the flexor hallucis longus, an
chance of recurrent infection. Oilier
pending culture and sensitivities con- important landmark that lies directly
authors 5 ' 7 ' 23 have reported that both
firmation, should be effective against posterior to the talar body and just
stages can be safely combined pro-
Staphylococcus and Streptococcus as medial to the neurovascular bundle.
vided that infection is not adjacent to
well as common gram-negative bacilli With the collateral ligaments under
and anaerobes. 18•20
the heel pad. Prior to closure, the fit
tension, they can be safely divided at
of the heel pad should be checked
the talar body with the oeurovascular
Surgical Technique b undle protected by gentle retraction.
(Figure 13). If too loose, excess skin
A Syme ankle disarticulation, al- can be removed from the proximal
The soft tissues are gently stripped
though not a technically difficult pro- from the superior, medial, and lateral skin edge. If too snug, 0.5 to LO cm
cedure, must be done with meticulous surfaces of the calcaneus with ca1·e to should be removed from tl1e tibia and
attention to preservation of the poste- avoid penetration of the cortex, espe- fibula. If infection is close to the heel
pad, the skin incision should be made
rior tibial neurovascular structures cially in osteoporotic bone. Bruising B
and the vertically oriented fat-filled of the posterior tibial vessels is to be more distal and the wound left open
chambers of the heel pad, which pro- avoided because it may lead to throm- for 7 tolO days to see if debridement
FigurE
vide shock absorption on heel con- bosis with loss of heel pad perfusion. and antibiotics have controlled the in- the in
tact. These points are well illustrated The bone hook is then transferred fection. Secondary closure without Of thE
and discussed in the classic articles by to the posterior aspect of the calca- wound tension will require that the missic
tibia be shortened as described by C, lat ,
Syme 1 and Harris. 21 neal tuberosity to expose and put ten- for tr
With the patient in the supine po- sion on the Achilles tendon (Figure Harris21 to accommodate interval surfac
sition and a thigh tourniquet in place, 11 ). The tendon is gently separated shrinkage of the heel pad flap and to
an anterior transverse incision is made from the calcaneus, taking care to remove the exposed plafond cartilage.
at the level of the ankle joint, ending avoid buttonholing the thin posterior Elmslie24 attempted to improve the Tl
medially and laterally at points 1 cm heel skin. The foot is then furtller cosmetic appearance of the residual and:
d istal and l cm anterior to t he midline plantar flexed and the heel pad is limb following a Syme procedure by by Sl
of each malleolus. These two points freed subperiosteally from the plantar using an incision that radically re- anter
are connected by a stirrup incision, calcaneal surface. The calcaneal origin duced the surface area of the heel pad ho lei
placed just anterior to the heel pad of the plantar fascia is divided trans- and by transecting the tibia and fibula ates 2
(Figure 9). If the tourniquet is inflated, versely to complete tl1e d isarticula- 2.5 cm proximal to the ankle joint. A.chi
the incisions may be taken directly to tion. The inside of the heel pad These two modifications greatly di- thq
bone; otherwise, the neurovascular should be palpated carefully to reveal minished the we.i ght-bearing surface ize ti
structures should be dealt with as the any flakes of cortical bone left from of both the heel pad and the distal heel
wound is deepened. Care must be stripping of the calcaneus. These tibia, leading to painfuJ prosthetic displ
taken to find and shorten all anterior should be meticulously removed to gait (Figure 14). tapir

~s. drain tube can be run between layers

n- of cast padding and out the top of the
:he cast, allowing its removal without dis-
ed turbing the cast after 24 to 48 hours.
ta! When a Syme ankle disarticulation
le- has been done for infection, it may be
:le- more appropriate to use a continuous
ib- closed irrigation stem to minimize re-
)Or currence of infection. Just before clo-
to 9 sure, a double-lumen catheter, such as
,tal a Shirley drai11 or Foley catheter, is
' fit modified and inserted through a lat-
an eral stab wound 6 (Figure 15). A Foley
,di- catheter is prepared by dividing it ob-
I in liquely proximal to the balloon. The
by smaller tube is attached to a bag of
lle- A sal ine solution and the larger one to a
the sterile urine collection bag. One li ter
tlso of saline solution is passed through
the wound every 8 hours until the
· be
'oot outflow is clear, usually by 2 to 3 days
etic postoperatively. Every 4 hours, the
,her wound is flushed by occluding the
,oth larger egress tube for 5 minutes, then
>r0- releasing it. A cast is applied immedi-
1t to
ately upon removal of the catheter,
e fit carefully molding the heel pad to a
:ked central and slightly forward position
skin under the tibia. The cast is reapplied
imal in the same manner at weekly inter-
cm vals for 4 to 5 weeks, when a walking
and heel is added (Figure 16). This tem-
heel porary prosthesis is changed when-
ever it becomes loose, but at least ev-
1ade
>pen
B c ery 2 weeks, until limb volume has
nent stabilized . At that time, measurements
Figure 14 Elmslie's modification of the Syme procedure. A, Diagram shows placement of for a prosthesis are taken, and a new
e in- the incision, which removes a major portion of the heel pad, and location of transection
hout walking cast is worn until the pros-
of the t ibia and f ibula, proximal to the ankle joint 1 in (2.5 cm). (Reproduced with per-
: the mission from Carson's Modern Surgical Surgery. London, England, 1924.) B, Anterior and thesis is ready.
i by C, lateral views of a right limb that underwent an Elmslie-type procedure 6 years earlier Occasionally, major anterior or
erval
for trauma. Walking in a prosthesis was painful because of the small weight-bearing medial skin defects proximal to the
surface of the truncated heel pad. ankle joint can be closed with sal-
1d to
fage. vaged sole skin extending distally
The heel pad flap can be accurately the tibia by a threaded or smooth pin, from the heel pad. Cru·eful trimming
e the
and securely centered under the tibia but these do not offer the security of and rotational placement of the flap
idual
by suturing the plantar fascia to the direct sutme of the plantar fascia or are essential. The initial bulkiness of
re by
the sole flap will resolve with progres-
v re- anterior tibial cortex through drill Achilles tendon to the tibia, when
sive weight bearing in temporary
l pad holes. Alternatively, Smith and associ- these latter techniques are combined
ates25 recommend tenodesing the with casting. prostheses (Figures 17 and 18).
1bula
joint. Achilles tendon through drill holes in Prior to closure and cast applica-
y di- the posterior t ibial cortex to neutral- tion, consideration should be given to Expected Functional
trface ize the pull of the triceps surae on the draining the large dead space created
heel pad, thus preventing its posterior by removal of the talus and calcaneus
Outcome
distal
the tic displacement. Other methods include to prevent hematoma formation. In Both the Syme ankle disarticulation
taping or transfixing the heel pad to trauma cases, a nonsutured suction and transtibial amputation retain tl1e

Fig1.111
follo
latio
the E
gooc
fitte,
Figure 15 Syme procedure. A, Note placement of the catheter posterolateral to the fib-
ula. Also note the oblique division of the catheter, which opens both lumens. B, Note
the wide spacing of the sutures and the supplemental use of adhesive paper strips. The
modified Foley catheter provides continuous irrigation with normal saline solution.
Note that "dog ears" have not been trimmed to avoid narrowing of the heel flap pedi-
cle. (Figure 2,8 reproduced with permission from Bowker JH, San Giovanni TP: Amputa-
tions and disarticulations, in Myerson MS (ed): Foot and Ankle Disorders. Philadelphia,
PA, WB SiiJunders, 2000.)
knee joint. A distinct advantage of the the absence of careful initial pros-
Syme, however, is preservation of thetic alignment of the heel pad and
end- weight-bearing along normal ongoing adjustments/refitting as nec-
proprioceptive pathways through the essary as normal atrophy occurs, the
heel pad (Figure 19). Gait studies heel pad may migrate posteriorly or
Figure 16 Syme procedure. A temporary Figu
demonstrate that patients with Syme in the coronal plane, even within the Sym,
weight-bearing prosthesis is applied after
disarticulations have increased ca- prosthesis, leading to painful weight- scan
4 to 5 weeks of non-weight-bearing
dence and velocity and consume less bearing and/or ulceration (Figure 20). casts, changed weekly. The temporary
Of SI
oxygen per meter traveled than do defe

In a review of the literature, Smith prosthesis is changed every 1O to 14 days
sole
persons with more proximal level am- and associates 25 found that heel pad until the leg volume has stabilized, when
won
putations or disarticulations. 26 the definitive prosthesis is fitted. It is im·
migration ranged from 7.5% to 45%,
portant that t he heel pad be continu·
Mi11imal prosthetic gait training is but in their series of 10 patients in ously held in weight-bearing line by cast·
required following a Syme procedure, whom Syme disa1"ticulation was aug- ing until fitting is accomplished. autl
chiefly the equalization of stride mented by Achilles tenodesis to the (Reproduced with perm,ss,on from tien
length and time spent in stance phase. posterior tibia, all heel pads remained Bowker JH, San Giovanni TP: Amputa· reg,
tions and disarticu/ations, in Myerson MS fun.
Even an insensate heel pad is remark- stable at a11 average of 18.5 months.
(ed): Foot and Ankle Disorders. Phi!adel·
ably activity tolerant, as noted by One of the adva11tages of the Syme qui1
phia, PA, WB Saunders, 2000.)
Srinivasan,27 who reported that pres- procedure is that it allows weight bear- und
sure sores of the heel pad developed ing directly on the heel pad without a hoo
in only 3 of 20 persons (15%) with prosthesis, at least for short distances. of this group were considered to have tior
Hansen's disease (leprosy) at an aver- Gaine and McCreath 2 studied 46 pa- "poor" residual limbs due to uncon- tie11
age of 5 years after Syme ankle disar- tients who had undergone Syme disar- trollable heel pad mobility or tibial ino
ticulation, despite loss of protective ticulations, at an average follow-up of cuts that were too proximal or not par· in
sensation. 22 years after surgery. T hey fo und that allel to the floor when the patient was Syn
Careful maintenance of the heel 32 patients (70%) could bear weight in the standing position. Nine of these mo
pad in a central weight-bearing posi- directly on the heel pad without a ten were unable to bear weight with- allo
tion beneath the tibia is essential. In prosthesis in their home. Another ten out a prosthesis because of pain. The wal

B c D E
figure 17 A 29-year-old woman with type 1 diabetes mellitus sustained extensive loss of skin over the anterior foot, ankle, and leg
following a spider bite. Note the intact heel pad. A, Preoperative view. B, Same lower limb about 10 days after open ankle disarticu-
lation with salvage of the heel pad and contiguous sole skin flap. C, Wound closure w ith sole f lap used to cover anterior defect. Note
the extreme bulkiness of the flap. D, Same limb 7 weeks later, after the patient had walked in two temporary prostheses. Note the
good incorporation of the sole flap and reduction in bulkiness. E, Same limb 9 months after closure. The patient had been successfully
fitted w ith a Syme prosthesis.
80% at both 3 and 5 years. In another

series, Birch and associates29 evalu-
ated 10 young adults (age 18 to 26
years) who had undergone Syme an-
kle disarticttlation between the ages of
2 and 12 years for fibular deficiencies.
The surgical criteria were equinoval-
gus ankle, 5 cm or more of tibial
shortening, and absence of at least
two lateral rays. All 10 wore a pros-
thesis without difficulty and all were
reported to have nounal psychologi-
cal adjustment to their impafrment.
Figure 18 A 63-year-old woman with hemiatrophy of the right foot was treated with a Nine of the 10 participated in recre-
,porary
dafter
Syme ankle disarticulation. A, Note the fixed varus deformity of t he foot and extensive ational sports, two in high school
scarring of the medial ankle and leg. B, Medial view 2 days postoperatively. At the time football.
,earing
of surgery, a portion of skin from the sole of the foot was used as a f lap to cover the
,porary
defect created by repositioning of the heel pad. Note the edema and duskiness of the
14 days
, when
sole flap . C, Medial view 8.5 months later. The flap was well incorporated and the
woman was a successful ambulator in a prosthesis.
Variants of Ankle
tis im·
:rntinu·
Disarticu lation
)Y cast· The Syme ankle disarticulation, be-
>lished. authors then compared 25 of these pa- Laughlin and Chambers 11 assessed
from tients with 25 transtibial amputees in functional level in a series of 20 pa- cause it involves removal of the talus
mputa· regard to level of activity and general tients who had undergone Syme and cakaneus, provides enough verti-
son MS function . The groups were found to be disarticulations 27 months postoper- cal clearance to fit a variety of
hiladef· dynamic-response prosthetic feet. In
quite similar, although those who had atively. Eighteen (90%) were commu-
undergone disarticulation in child- nity ambulators, 11 (55%) could walk some patients, however, the heel pad
hood bad fewer problems with func- 3 or more blocks, and 16 (80%) could remains unstable unless constrained
:o have tion and the residual limb. Two pa- climb stairs. All 18 community ambu- by the socket, making it impossible to
mcon· tients had a Syme ankle disarticulation lators wore a prosthesis the entire walk prosthesis-free without the risk
r tibial in one leg and a transtibial amputation day. 11 Vveaver and associates 12 re- of displacing the heel pad.
.ot par· in the other leg; they preferred the ported successful prosthetic fitting of To allow the hindfoot amputee to
mt was Syme ankle disarticulation because its 28 of 29 patients (97%) with Syme walk securely without the need for an
>f these more natural proprioceptive feedback disarticulations who achieved pri- expensive prosthesis, Pirogoff 0 advo-
t with· allowed easier limb placement while mary healing. They noted cumulative cated a calcaneotibial arthrodesis to
in. The Walking or stairclimbing.2•28 ambulatory rates of 92% at 1 year and maintain heel pad stability and mini-

A B A
Figure
Figure 19 Mature Syme ankle disarticulation. A, Lateral and B, AP Figure 20 A woman who underwent a Syme disarticulation of the
will re
radiographs. Note t he thickness of t he fatty heel pad, which pro· left limb sustained a fixed posteromedial displacement of t he heel
are ex·
vides excellent weight-bearing characteristics when contained pad 1 year after t he initial surgery w hile walking in a prosthesis
Note t
within a prosthesis socket. Also note the well-centralized position that no longer f it intimately because of tissue atrophy. A, Preop-
heel p
of the heel pad in both views. (Figure 19 B is reproduced from erative appearance of the limb. B, Appearance of the residual limb
Bowker JH: Minor and major lower limb amputations in persons 7 years after surgical release and realignment of t he heel pad be·
with diabetes mellitus, in Bowker JH, pfeifer MA (eds): Levin and neath the tibia. The woman was actively wearing the prosthesis 14
O'Neal's The Diabetic Foot, ed 6. St. Louis, MO, Mosby, 2001.} to 16 hours daily. (Figure 20 Bis reproduced from Bowker JH: Minor
and major lower limb amputations in persons with diabetes mel-
litus, in Bowker JH, Pfeifer MA (eds): Levin and O'Neal's The Dia·
.. "' . betic Foot, ed 6. St. Louis, MO, Mosby, 2001.)
A disadvantage of the original bony union. Baumgartner5 recom-

Pirogoff method compared with the m ends an ex1:ernal fixator for 6 to 8
Syme procedure is that the thinner weeks, and Camilleri and associates31
skin over the posterior aspect of the place screws across the denuded sur-
calcaneus becomes weigh t bearing, faces. Transection of the Achilles ten-
rather than the plantigrade fleshy heel don is advised to reduce the posterior
pad. To correct this shortcoming, displacement force on the calcaneus.5
several modifications have been pro- The Pirogoff procedure as modi-
posed. In the Lefort-Neff variation (G fied is well suited to selected cases of
Figure 21 Diagram showing the original Neff, MD, personal communication, trauma. Livingston and associates
32
Pirogoff calcaneotibial arthrodesis. Stip· 2003), the superior calcaneus is sec-
also advocate it for cases of d iabetic FigurE
pied areas of bone are excised. (Courtesy tioned in the transverse (horizontal)
foot infection. Baumgartner,5 how- illeri
of Professor G. Neff.) plane. The calcaneus is shifted proxi- Note
ever, does not recommend it in pa·
mally and anteriorly, thus keeping the sition
tients with neuropatl1y because of the t ion c
mize limb-length discrepancy while heel pad plantigrade. The malleoli are
typically prolonged time for bony traliz1
walking barefoot or in a simple boot. trimmed to improve cosmesis, but the
union to occur in these cases. The screw
This procedure has been widely used calcaneal tuberosity is retained to as-
Boyd33 calcaneotibial arthrodesis is
in Europe over many decades for in- sist in suspension of the prosthesis
juries sustained during war. The orig- (Figure 22) . To provide a more cos· similar to the modified Pirogoff pro· Ai
inal procedure is as follows: After metic prosthetic fitting, Camilleri and cedure. Following midtarsal disarticu- tus f
m idtarsal disarticulation, the talus is associates 31 recommend shifting the lation, the calcaneus is divided trans· proc<
removed. The calcaneus is then sec- calcaneus anteriorly, directly beneath versely just distal to the peroneal sion
tioned in the frontal (vertical) plane the tibia, after excising the superior tubercle. Cancellous bone is exposed limb
and its anterior portion is discarded. one third of the bone. This eliminates on the superior calcaneus, distal tibia, comf
The d istal tibia is divided transversely posterior protrusion of the tuberosity. and malleoli. The calcaneus is shifted It is
through the canceIJous metaphysis The anterior projection of the calca- anteriorly and superiorly and fixed ofth
and the calcaneus is then rotated for- neus and the malleoli are trimmed to securely to the tibia (Figure 24). This cult,
ward 90° to contact the denuded infe- match the width of the tibial metaph- procedure is also subject to maltmion has
rior tibia30 (Figure 21 ). The two ysis (Figure 23). With these methods, or nonunion if the bones are not well beca1
bones are then securely fixed. furn fixation is essential to encourage fixed (Figures 25 and 26). ance

Chapter 36: Ankle Disarticulation and Variants: SUigical Management 469
Figure 22 The Lefort-Neff modification of the Pirogoff procedure. A, Diagram of the Lefort-Neff modification. Note that the heel pad
of the will remain plantigrade as the calcaneus is shifted anteriorly and superiorly to contact the osteotomized tibia. Stippled areas of bone
e heel are excised. B, Lateral and C, AP radiographs of a lower limb that underwent the _Lefort-Neff modification of the Pirogoff procedure.
,thesis Note the prominence of the calcaneal tuberosity, which assists in suspension of the prosthesis. D, Anterior view. Note the plantigrade
)reop- heel pad. (Courtesy of Professor G. Neff.)
11 limb
ad be-
esis 14
Minor
·s mel-
,e Dia-
:com·
5 to 8
iates31
d Sur·
:s ten-
;terior
ieus.5
modi-
lses of
32
iates
iabetic Figure 23 Radiographs of a lower limb that underwent the Cam- Figure 24 Radiographs of a lower limb that underwent a Boyd
how· illeri modification of the Pirogoff procedure. A, Lateral view. amputation. A, Lateral and B, AP radiographs. Note the posterior
Note the anterior translation of the calcaneal tuberosity to a po· prominence of the calcaneal tuberosity, which assists in suspen·
in pa·
sition directly beneath the tibia. Also note that the anterior por- sion of the prosthesis.
of the tion of the calcaneus has been excised. B, AP view. Note the cen-
bony tralized position of the calcaneus and its fixation with crossed
s. The screws. (Courtesy of Dr. D Menager.)
esis is
ff pro· As noted above, the origirlal impe- velopment of low-profile Syme feet trauma or infection has left the hind-
articu· tus for development of the Pirogoff and carbon fiber technology, however, foot unaffected. By preserving heel
trans- procedure and its variants was provi- it is now possible to fit a dynamic- pad weight bearing along normal
!roneal sion of a stable heel pad with less response foot even within the 3- to proprioceptive pathways, these proce-
xposed limb-length discrepancy to allow a 4-cm space distal to the residual lin1b dures at the ankle provide a more
11 tibia, comfortable gait without a prosthesis. following a Pirogoff procedure. 32 energy-efficient gait than does trans-
shifted It is ironic that the length advantage tibial amputation and also require
i fixed of these procedures has made it diffi- minimal prosthetic gait training. The
l). This cult, until recently, to fit a foot that
Summary heel pad is remarkably activity toler-
tlunion has undergone ankle disarticulation Ankle disarticulation and its variants ant, even if insensate, provided that it
10t well because of insufficient vertical clear- should be considered in lieu of a trans- is held firmly in place under the tibia
ance from the ground. With the de- tibial amputation whenever foot by an iutimately fitted prosthetic

F
2
20. l
p
b
}<
21. I-
t,
1
22. (
}
2
Figu re 25 Right lower limb of a 57-year-o ld woman who underwent a Boyd am- Figu re 26 Lowe r limb of patient who underwent a
Boyd amputat ion . A, Lateral radiograph showing 23.F
putation. A, Note th e poo r cosmesis due t o a medial sh ift of the calcaneus. B, AP
radiograph showing ma lu nio n. C, Lateral rad iograph show ing bot h excessive posterior displacement of th e ca lca neal frag ment s
posterior d isplacement of the calcaneus and inadequate fixation w it h wi re subsequent t o inadequat e f ixat ion to the inferior e
loops. (Reproduced with permission from Bowker JH, San Giovanni TP: Amputa- t ibia. The pat ient was unable to bear we ight on f.
tions and disarticulations, in Myerson MS (ed): Foot and An kle Disorders. Phila- t he limb beca use of pain. B, Corresponding lateral s
delphia, PA, WB Saunders, 2000.) photograph of th e same limb. Not e t he promi-
nence of t he dista l anterior t ibia a nd the posterior
promine nce of t he calcaneal fragment with proxi- 24. J:
ma l creasing of the skin. The residu a l limb was suc- i:
cessfully converted t o a Syme ankle disarticu lation
by excision of t he calca neal fragment .
socket. Careful prosthetic fo llow-up is 5. Baumgartner R: Forefoot and

12. Weaver FA, Modrall JG, Baek S, et al:
essential to maintain this position, as Hindfoot Amputations. Paris, France,
Sym e ampu tation: Results in patients
calf atrophy inevitably develops. Al- Ed itions Scientifiques et Medicales
with severe forefoo t ischem ia.
though achieving a cosm etically ac- Elsevier, SAS, 200 I , pp 4 -5.
Cardiovasc Surg 1996;4:8 l-86.
ceptable distal socket contour is more 6. Wagner FW Jr: The Syme ankle disar-
13. Dickhau t SC, DeLee JC, Page CP: Nu-
difficult than with a transtibial pros- ticulation: Surgical procedures, in
tritional status: Importance in predict-
Bowker JH, Michael JW (eds}: Atlas of
thesis, the fact that ankle d isar ticula- ing wound healing after amputation.
Limb Prosthetics: Surgical, Prosthetic,
tion and its variants allow the amputee f Bone Join t Surg Arn 1984;66:71-75.
and Rehabilitation Principles, ed 2.
to engage comfortably in a wide range 14. Fahey TJ III, Sadaty A, Jones WG II,
Rosemont, IL, American Academy of
of activities sho uld lead to m uch more Orthopaedic Surgeons, 2002, p 413. Barber A, Smoller B, Shires GT: Diabe-
frequent use of these procedures. (Originally published by Mosby-Year tes impairs the late inflam matory re-
Book in 1992.) sponse to wou nd healing. J Surg Res
1991 ;50:308.
7. Bowker JH, Bu i VT, Redman S, et al:
References Syme amputation in diabetic dysvas- 15. Schaffer MR, Tan try U, Efron PA,
1. Syme J: On amputation at the ank le cular patients. Orthop Trans 1988;12: Ahrendt GM, Thornton FJ, Barbu! A:
joint. Land Edinb Mon J Med Sci 1843; 767. Diabetes-impaired heali ng and re-
26:93-96. duced wou nd nitric oxide synthesis: A
8. Pinzu r MS, Morrison C, Sage R, Stuck
possible pathophysiologic correlation.
2. Gaine WJ, McCreath SW: Syme's am - R, Osterman H, Vrbos L: Syme's two-
stage am p utation in insul in-requi ring
Surgery 1997;121:5 13- 519.
putation revisi ted. J Bone Joint Surg Br
1996;78:46 1-467. d iabetics with gangrene of the fore- 16. Yue DK, McLennan S, Marsh M, et al:
foot. Foot Ankle J991;1 1:394-396. Effects of experimental diabetes, ure-
3. Maz.et R Jr: Syme's amputation: A
9. Sarmiento A: A m odified su rgical- m ia and malnutrition on wound heal-
follow-u p study of fifty-one adults
pros thetic approach to the Syme's am- ing. Diabetes l 987;36:295-299.
and thirty- two children. / Bone Joint
Su,g Arn 1968;50:1549-1563. putation. A follow-up repo rt. Clin 17. Yue DK, Swanson B, McLennan S, et
Orthop 1972; 85:11-15. al : Abnormalities of granulation tissue
4. Kruger LM: Lower limb deficiencies:
10. Francis H, Robert JR, Clagett P, and collagen formation in experimen-
Surgical management, in Bowker JH,
Gottschalk F, Fisher DF: The Syme tal d iabetes, uraemia and malnutri-
Michael JW (eds}: Atlas ofLimb Pros-
amputation: Success in elderly diabetic tion. Diabet Med l 986;3:221-225.
thetics: Surgical, Prosthetic, and Rehabil-
itation Principles, ed 2. Rosemont, IL, patients with palpable an kle pulses. 18. Grayson ML: Diabetic foot infections:
American Academy of Orthopaedic J Vase Surg 1990;12:237-240. Antimicrobial therapy. Infect Dis Clin
Surgeons, 2002, p 795. (Originally 11 . Laughlin RT, Chambers RB: Syme am- North Am 1995;9:143-161.
published by Mosby-Year Book in putation in patients with severe diabe- 19. Lipsky BA: Evidence- based antibio tic
1992.) tes mellitus. Foot Ankle 1993;14:65-70. therapy of diabetic foot in fect ions.

FEMS Immunol Med Microbiol 1999; London, England, Cassel & Company, long-term physical and psychological
267-276. 1924, p l32. functional status. J Bone Joint Surg Am
20. Lipsky BA, Berendl AR: Principles and 25. Smith DG, Sangeorzan BG, Hansen 1999;81: 1511-1 518.
practice of antibiotic therapy of dia- ST, Burgess EM: Achilles tendon teno- 30. Pirogoff NJ: Osteoplastic elongation
betic foot infections. Diabetes Metab desis to prevent heel pad migration in of the bones of the leg in amputation
Res Rev 2000;16(suppl I):S42-S46. the Syme's amputation. Foot Ankle of the foot. Voyerno Med J 1854;68:83.
1994;15: 14-17.
21. Harris RI: Syme's amputation: The 31. Camilleri A, Anract P, Missenard G,
technical details essential for success. 26. Waters RL, Perry J, Antonelli D, Hislop
Lariviere JY, MeDager D: Amputations
J Bone Joint Surg Br 1956;38:614-632. H: Energy costs of walking of ampu-
et desarticulations des membres:
22. Oznur A: Syme ankle disarticulation: Membre inferieur, in Encyclopedie
tion. J Bone Joint Surg Am 1976;58:
A simplified technique. Foot Ankle Int Medico-Chirurgicale: Paris, France,
42-46.
2001;22:484-485. Editions Scientifiques et Medicales
ent a 27. Srinivasan H: Syme's amputation in
23. Pinzur MS, Smith D, Osterman H: Elsevier, SAS, 2000, pp 6-8.
,wing insensitive feet: A review of twenty
ment Syme ankle disarticulation in periph- cases. J Bone Joint Surg Arn 1973;55: 32. Livingston R, Jacobs RL, Karmody A:
ferior eral vascular disease and diabetic in- 558-562. Plantar abscess in the diabetic patient.
it on fection : The one-stage versus two- 28. Murdoch G: Syme's amputation.JR Foot Ankle 1985;5:205-213.
1teral stage procedure. Foot Ankle Int 1995; 33. Boyd HB: Amputations of the foot
CollSurgEdinb 1976;21:15-30.
rom i-
16: 124-127. 29. Birch JG, Walsh SJ. Small JM, et al: with calcaneotibial arth rodesis. J Bone
terior
Jroxi- 24. Elmslie RC: Section on amputations, Syme amp utation for the treatmeDt of Joint Surg 1939;21:997-1000.
s suc- in Carson's Modern Operative Su,gery. fibular deficiency: An evaluation of
ation
t al:
ents
Nu-
edict-
ion.
'5.
II,
>iabe-
re-
~es
ilA:
sis: A
1tion.
et al:
ure-
heal-
;, et
tissue
men-
n-
:ions:
Clin
iotic
IS.

Ankle Disarticulation and
Variants: Prosthetic Management
Gary M. Berke, MS, CP
Introduction
Nearly a centmy ago, Marks' Manual chanics of gait and alignment and its eas of thin skin, especially around the
of Artificial Limbs noted that "amputa- relationship to the strength and fw1c- anterior distal scar line. Strength and
tions through the ankle articulations tion of a prosthesis follows . A clear range of motion of the remaining
with or without the malleoli, flaps understanding of the mechanics, bio- joints of the affected limb as well as
formed of heel tissues, provide mechanics, and function involved in the contralateral limb should be eval-
stumps that can be fitted with artifi- prosthesis wear in this population is uated. The activity level before ampu-
cial limbs in advantageous ways." 1 As critical to improving the effectiveness tation and the ambulation goals of
surgical techniques and technologi- of ankle disarticulation prostheses. Fi- the patient should be noted. These
cally advanced components continue nally, two case studies are described. factors will have a significant effect on
to evolve, the potential functional the type of prosthesis prescribed.
ability of the lower limb amputee is Evaluation must include an assess-
enhanced and the Syme ankle disar- Evaluation and ment of the patient's abi lity to com-
ticulation may become more preva- Staging of Care fortably bear weight on the distal end
lent. Ankle disarticulation is arguably of the residual limb, as well as the
the most functional level of amputa- As with any amputation, evaluation presence (or absence) of the medial
tion because the length of the residual of the patient with an ankle disarticu- and distal malleoli. The position of
limb leaves a significant lever arm to lation is critical The residual limb the distal heel pad-medial, lateral, or
distribute forces and control a pros- should be free from open wotmds, centralized-should also be noted.
thetic device. 2 In addition, unlike the and care should be taken to assess ar- Stability of the pad will determine
more distal amputation levels, the
complete replacement of the foot
equalizes limb length and facilitates TABLE 1 Prosthetic Advantages and Disadvantages of a Syme Ankle
near-normal gait, activity level, and Disarticulation
energy consumption in healthy indi-
Contraindications for
viduals. Advantages and disadvan- Advantages Disadvantages Prosthetic Fitting
tages of ankle disarticulation with re- Full weight-bearing Bulbous nature of distal Poor heel pad integrity
gard to prosthesis use are summarized potential on t he distal end complicates cosmetic
in Table L. end of the res idual limb prosthesis
This chapter discusses the value of Natural gait pattern Healing is sometimes Open wound or unhealed
difficult surgical site
ankle disarticulation and provides the
Self-suspending prosthesis; Limited room distally Medialized or unstable heel
historical basis for the design and allows walking without a hinders foot selection pad
construction of prostheses for this prosthesis for short and significantly
patient population. Methods of eval- distances, if necessary complicates the
uation, staging of care, design con- alignment procedure
siderations, design alternatives, and Minimal disturbance to Some designs have poor Pain independent of
growth potential in structural integrity3 prosthesis or ambulation
components for an appropriate ankle children
disarticulation prosthesis are re- Early fitting
viewed. A discussion of the biome-

Figu1
Figure 1 Severe medial shift of t he heel grap
pad following ambulation without a mall•
prosthesis. Figure 2 Historical ankle disart iculation prost hesis. (Reproduced from Marks GE (ed): terfa
Manual of Artificial Limbs: An Exhaustive Exposition of Prosthesis. New York, NY, AA
Marks, 7907, p 37.)
whether the patient should ambulate tha11
without a prosthesis. A hypermobile thes
Design direction is critical to comfort and
pad may shift to the side during am- larg•
continued skin protection. The hori-
bulation without a prosthesis, making Considerations zontal component of the force against
botl
later prosthetic fitting extremely diffi- to ti
For comfortable transmission of the the posterior distal regions of the re- bult
cult (Figure 1). Knee joint instability
forces for ambulation and to provide sidual limb must be accommodated the J
must be noted and addressed either
ease of donning and doffing, the during push-off, as well as anterior con1
by alignment or by extending the
prosthesis must have tl1e following distal pressure during heel strike. mal
prosthesis above the knee with supra-
condylar support or a thigh lacer. features 4 : (1) The prosthesis m ust (5) Adequate stabilization must be tivel
One of the advantages of ankle dis- provide comfortable support of the provided against the torques about tact
limb on the distal end, the proximal the long axis of the leg. Three-point swu
articulation is that the patient can be
fitted immediately after the amputa- portion of the socket brim, or both. stabilization against the medial and the
tion with a partial weight-bearing cast (2) Firm support must be provided lateral flares at the anterior/proximal met
applied by the surgeon or prosthetist. against the anteroproximal surface of margin of the tibia and a flattening of loc.a
A standard cast with good padding the leg to absorb the significant pres- the posterior/proximal contour can O!llJ
and a walking post on the distal end sures present at the time of push-off. be highly effective in providing the late:
will allow early limited weight bearing Careful fitting against the wedge-like necessary torque resistance. If insuffi- due
and controlled ambulation with an medial and lateral surface of the tibia cient stabilization is provided, torques ho"
assistive device. The first prosthesis or application of a patellar tendon acting on the distal end of the resid- feet
may be fitted soon after suture re- force can satisfy this requirement. ual limb will result in skin abrasion. the
moval, assuming adequate healing has (3) Similar support must be provided (6) Finally, the prosthesis must pro- tact
occurred. The patient may begin full against the posterior surface of the leg vide adequate relief for the bulbous mu:
weight bearing upon fitting of the to absorb pressmes that occur at the distal end to allow for ease in donning sun
first prosthesis and usually will begin time of heel contact. (4) Witl1in the as well as suspension. sidt
ambulating without an assistive de- socket, there must be provision for The design of the ankle disarticula-
vice within the first few weeks. Physi- the shifting of the center of pressure tion prosthesis is unique (Figure 2).
cal therapy for gait training is not against the distal end of the residual Ankle disarticulation results in an
usually required unless significant limb during gait. Prevention of the end-bearing residual limb; conse- Rae
gait anomalies or other medical com- relative motion between the stmnp quently, the prosthesis may be de- stre
plications are present. and the socket in an anteroposterior signed with less proxin1al pressure cur

Chapter 37: Ankle Disarticulation and Variants: Prosthetic Management 475
Figure 3 A, Anterior view of a conventi onal Syme ankle disarticulation. B, Xeroradio- Figure 4 Cross section of an expandable
graph of a Syme ankle disarticulation resid ual limb within a prosthetic device. The distal silicone bladder ankle disarticulation
malleoli have been removed, and the self-suspending prosthesis is fitted with a soft in- prosthesis, fabricated using the "lost
'ed): terface. wax" method. The tubular shape of the
AA outside wall allows the limb to pass
through the narrower portion of the ex-
than is required for transtibial pros- is the smallest. During normal ambu- pandable liner.
theses. The rustal circumference, being lation, the socket will undergo three
and
larger than the ankle circumference, is types of stress-compression stresses
ori- socket is tubular in shape (oval or
both an advantage and disadvantage from direct thrust load, bending
1inst nearly round in cross section) and
to tl1e user. The advantage is that this stresses resulting from a tendency for
: re- therefore very strong, with the overall
bulbous end may be used to suspend the structure to bow posteriorly, and
ated circumference being determined by
the prosthesis. Application of carefully bending stresses from the tendency to
:rior the circumference of the bulbous dis-
contoured pressure proximal to the bow laterally. 4 At heel strike, moder-
rike. malleoli can comfortably and effec- ate compressive loads occur on the tal end and liner.
t be The liner usually must be split on
tively keep the prosthesis in close con- posterior side of the prosthesis, and
bout tact with the residual limb during tensile loads occur on the anterior one or two sides to allow the bulbous
,oint swing phase. The disadvantage is that side. During the terminal stance distal end to pass through the nar-
and tl1e large distal segment is often cos- phase of the gait cycle, significant rower circumference of the ankle re-
imal metically unappealing because of its compressive loads occur on the ante- gion of the liner. Permutations of this
1g of location and size. Some authors rec- rior surface of the socket and sub- basic design are limited only by mate-
can ommend removing the medial and stantial tensile loads occur on the rials and creativity. Silicone bladders,
; the lateral aspects of the malleoli to re- posterior aspect. When the structure elastic liners,5 and double-wall sock-
;uffi- duce the bulk of the residual limb; of the socket is breached, as witll a ets fabricated by the "lost wax"
:ques however, care must be taken to not af- window or hole to permit donning, method all can provide suspension
esid- fect the suspension benefit. Despite the rigidity and durability of the and ease in donning and doffing but
.sion. the bulbous nature of the Limb, con- structure is significantly compro- are difficult to adjust. These are the
pro- tact throughout tlle residual limb mised. Several socket variations have strongest and most durable type of
lbous must be preserved to spread the pres- been developed to address this con- ankle disarticulation sockets because
ming sures of ambulation over the entire re- cern. there is a uniform cross-sectional area
sidual limb (Figure 3). The "stovepipe" prosthesis can be without any breach of the rigid exter-
icula- fabricated in a va1·iety of ways. One nal structure (Figme 4).
re 2). method incorporates a removable The Canadi.an ankle disarticulation
nan Design Alternatives liner ( usually high-density closed cell prosthesis, first described in 1954 by
onse- Radcliffe4 observed that the highest foam) tllat maintains the shape of the the Veterans Administration in Can-
e de- stresses in a prosthetic socket will oc- lin1b on the inside and is tubular in ada, is a bivalved socket with a poste-
:ssure cur where the transverse cross section shape on the outside. The rigid outer rior door that extends to the proximal

brim of the socket, allowing easy in- between the distal end of the limb sorb some of the in1pact of ambula-
sertion of the limb into the device. and the floor. In the past, the solid tion yet firm enough to provide
The door is buckled or strapped in ankle- cushion heel (SACH) foot was adequate forward propulsion of the
place for ambulation. Such posterior the only available option for this level limb. The knee joint helps to com-
opening designs are structmally weak, of a mp utation to offer a smooth load- pensate for some of the loss of nor-
with high stress concentrations where ing response, because of the heel mal shock absorption by flexing
the abbreviated anterior panel meets cushion that absorbs some of the ini- slightly more at initial contact than in
the hemispherical base. With an end- tial impact during the early stance normaJ gait. This increase in knee
bearing residual limb, the tensile phase of gait. Currently, several alter- flexion also allows fo r a natural-
forces on the anterior panel are actu- natives further improve ambulation. appearing gait pattern. 4
ally increased, compared with the Flexible-keel feet with a SACH-type As the patient moves from initial
same posterior opening device with- heel offer improved shock absorption contact through the loading response
ou t end bearing.4 Reinforcing the de- over uneven terrain and are available portion of the gait cycle, the center of
vice with materials resistant to tensile in ankle disarticulation styles. Dy- m ass will fall between the heel and
stress at the critical junctures is there- namic-response feet are also available the toe of the prosthetic foot, and the
fore essential. in ankle disarticulation configura- ground -reaction force will be poste- Figu
In 1959, the Veterans Administra- rea c
tions, but because the leaf-spring keel rior to tl1e cen ter of mass. This will
grol
tion Prosthetics Center in New York of a dyn amic-response foot requires cause a torque about t he socket in a mas
described the medial-opening Syme increased force for deflection, the forward direction. In an effort to con- fore
prosthesis.6 The opening on the me- socket must be designed to distribute trol this forwa rd moment of the of !
dial side resembles a small door and the increased forces tl1at occur in ter- socket, tl1e knee joint extends and the pro,
terminates well below the proximal this
minal stance in a comfortable man- residual limb presses against the walls for,c
trimline of the socket. The opening is ner. of the prosthesis in an attempt to slow the
usu ally medial because of the p romi- the forward progression of the socket. of r
nence of the medial malleolus and the In doing so, the forces on the residual sity
natural cmvature of the residua] Biomechanics of Gait limb are significantly higher in the
the
fore
limb. 7 The opening must be large and Alignment area of the posterior proximal and the pos1
enough to accommodate the distal re- anterior distal aspects of the socket
The ultimate goal for individuals with Dw
sidual limb, but not so large as to (Figure 5) . Th e sagittal position of the corr
ankle disarticulati.ons is to return to
compromise structural integrity. In a prostl1etic foo t relative to the socket pos·
the highest level of fw1ction possible.
prosthesis with a medial window, the and the durometer of the prosthetic
A complete understanding of the me-
anterior edges of t he medial opening heel will have a significant impact on
chanics and biomechanics of gait is aro
are under significant compressive the gait pattern, the magnitude of
necessary to achieve this goal. rio1
stresses during the late stance phase
Obtaining appropriate alignment, force on the residual limb, and ulti- slig
of gait. (Because the posterior edges
although somewhat difficult in the mately the long-term comfort and is c
are under only moderate compression
ankle disarticulation prosthesis, is function of the device. the
at early stance phase and are usually
critical to achieving an appropriate the
not involved in structural failure, they Loading Response to
are not discussed in this chapter. ) To gait pattern. The complicating factor foo
is that the lin1ited space between the Midstance the
increase the resistance to local com-
pressive stress, the wall thickness of socket and the foot does not permit After a period of knee flexion during poi
the socket must be increased, thereby use of an adjustable alignment unit. initial contact, the knee begins to ac- pre
increasing the overall cross-sectional This forces tl1e practitioner to "cut tively extend through loading re- gai
area of the socket. 4 Contrary to the and paste" the position of the foot sponse. At this phase of gait, because the
mechanics of the posterior-opening until an appropriate socket/foot rela- of the lack of true ankle plantar flex- pre
prosthesis, when end bearing is al- tionship is achieved. ion in the prosthetic foot, the knee ing
lowed within the medial window will extend fully to stabilize the sys- spc
Initial Contact to Loading tem. This is contrary to normal gait, the
prosth esis, the magnitudes of the
forces around the opening are re- Response in which the knee continues to flex at as.
8
duced significantly.3 The lack of space (from resid ual Emb this phase to act as a shock absorber. pre
to floor) inherent in the ankle disar- The horizontal pressures around ver
ticulation level of amputation pre- the proximal posterior portion of the ing
Components cludes the use of certain feet, espe- prosthesis at initial contact decrease of
The appEcation of prosthetic feet to cially those with articulating ankles. during the loading response phase of me
an ankle disarticulation socket is At initial contact, the heel of the pros- gait and become more vertical. If the eff,
complicated by the minimal distance thetic foot must be soft enough to ab- limb is end bearing, the pressures is c

la-
ide
,he
Extension' •
m- force
or-
mg
I lU
11ee
:al-
tial
nse
r of
Ground-reaction
force vector
j:Y
md
the Figure 6 As the patient continues Figure 7 Vertical forces at midstan ce.
ste- Figure 5 Init ial contact. F = Ground- through midstance, the ground-reaction Note the socket/foot angle in this exam-
reaction force; b = Distance from the fo rce vector moves anterior to the weight ple is approximately 85°.
will ground-reaction force to t he center of line. This provides an extension moment
11 a mass; D = Approximate location of distal t o t he knee and redirects the socket pres-
:on- forces on the residual limb at this phase sures to the proximal anterior and poste- foot is parallel to the floor at mid-
the of gait; P = Approximate location of rior limb. stance and creates a slight varus
proximal forces on the residua l limb at
the thrust at the knee. This foot position
this phase of gait; V = Resultant vector
ralls force determined by the distance from will keep the pressures of ambulation
;low Midstance to Terminal
the ground-reaction force to the center focused in the pressure-tolerant prox-
:ket. of mass, the speed of walking, the den- Stance imal medial and distal lateral regions
dual sity of t he heel of the foot, the density of As the gait cycle shifts from midstance
the heel of t he shoe, and the opposing
of the socket and will result in a natu-
the to heel-off, the knee continues to play ral and comfortable gait pattern.
forces at D and P. Should the proximal
I the posterior wall be lowered, the pressur,e at an active role in the continuation of a When significant medial bowing of
,cket D will increase significantly t o attempt to smooth gait pattern by compensating the tibia is present, the foot is placed
f the compensate for the decreased control for the lack of range of motion at the at the most lateral aspect of the distal
,cket posteriorly. ankle. The pressures on the residual socket that is technically feasible.
1etic limb shift to proximal anterior and Transverse foot rotation should
:ton around the distal end shift from ante- distal posterior as the patient tries to mimic that of the opposite side (Fig-
e of rior to straight distal and then to overcome the knee extension moment ure 8).
ulti- slightly distal posterior as midstance from the ground-reaction force being
and is completed. The actual location of anterior to the knee joint. The patient Ground-Reaction Forces
the d istal residual limb pressure when must use active knee flexion to over- and Energy Consumption
the foot is flat is determined by the come these pressures and ambulate The pattern of ground-reaction forces,
foot/socket angular relationship and comfortably. Peak pressures occur at centralized in the prosthetic foot, sup-
the amount of proximal anterior sup- the anterior proximal portion of the ports t he notion that the ankle disar-
Jiing port given the residual limb inside the socket during this phase of gait and ticulation amputee has a normal lever
o ac- prosthetic device. 6 At this phase of must be controlled by an appropriate arm for push-off at late stance that ac-
; re- gait, the body is moving forward over proximal contour and enhanced counts fo r a smooth and energy-
cause the prosthesis and the subsequent socket construction. The peak knee efficient gait pattern.9 The ankle disar-
flex- pressures within the device are chang- extension moment occurs at the be- ticulation amputation has been shown
knee ing considerably. Through loading re- ginning of the terminal stance/ to be even more energy-efficient than
! sys- sponse, tl1e center of pressure w1der preswing phase of gait. The greatest midfoot amputations.10· 12 This sur-
. gait, the prosthetic foot is moving forward test of the socket's structural integrity prising phenomenon seems to be due
lex at as a result of load acceptance onto the will occur at this phase of the gait cy- to the long linlb length and adequate
rber. 8 prosthetic foot. Consequently, the cle (Figure 7). lever arm of the prosthetic foot with
·ound vertical ground-reaction force is mov- an ankle disarticulation prosthesis.
Mediolateral Foot
)f the ing from behind the knee to the front There is little functional disparity
:rease of the knee, causing an extension mo- Placement, Angulation, between an individual with an ankle
ase of ment at the knee joint (Figure 6). The and Toe-out disarticulation prosthesis and one
If the effect of coronal-plane foot position Mediolateral foot placement should with no amputation. 13 Patients with
ssures is discussed below. be such that the plantar aspect of the ankle disarticulation prostheses sel-

and reclosure of a small necrotic area tion. Examination of the skin showed mad
on the lateral aspect of the scar line, good total contact throughout the rean
the wound eventually healed well. At sidual limb/socket interface, with no arou
follow-up approximately 3 weeks areas of significant redness or irrita- ducE
later, the patient had no pain in the tion. The previously scabbed area was ure
residual limb. A slight eschar was improved with use of the prosthesis. jum
present on the lateral portion of an He returned 1 month later, at which the,
anterior scarline. The heel pad was time he was ambulating without an iog
centralized and stable, and the patient assistive device. He had increased his care:
ambulated in a high-top tennis shoe sock ply to account for some limb and
with padding, requiring the use of bi- shrinkage. nece
lateral axillary crutches fo r balance tivit
and comfort. Case Study 2 of ac
The patient had smoked 50 packs A 25-year-old man sustained an open care:
of cigarettes per year for the past tibia and fibula fracture that required aspe
38 years. His past medical history in- external fixation and several surgical tens:
cluded high blood pressure and coro- interventions after a motorcycle acci- crea.
nary artery disease. He had two incident 5 years ago. He had an avulsion neec
dents of myocardial infarction and injury to the dorsum of his foot that dist~
underwent cardiac bypass surgery was nonsalvageable; he ultimately lost dym
7 years ago. He was cleared for all ac- his foot, but the hindfoot was pre- for I
tivities by his cardiologist. At the time served. He elected to have a Syme and
Figure 8 As the patient arrives at mid· pros
stance and shifts the body weight over of presentation, he used no medica- procedure rather than a transtibial
t he prosthesis, t he ground-reaction force tion and appeared healthy. amputation at that time. Following a the
through the foot w ill be medial to the The patient's goal was full-time lengthy hospitalization, he was dis- carb
weight line, causing a torque about the
community ambulation; he had no charged home but returned to the gait
kn ee in a varus direction. This figu re acti,
shows the typical coronal-plane foot interest in high-impact activities. He clinic after falling onto the residual
was somewhat concerned about the limb, opening the suture line approx- as le
placement on an ankle disarticulation
prosthesis. Note t he valgus appearance of appearance of his prosthesis, but imately 2 cm on the medial side. The beca
t he ankle during swing phase, and the wound was allowed to heal by second- iog
overall he was ready to abandon
lateral posit ion of the foot on t he distal
crutches and resume fishing and gar- ary intention and healed without fur- posi
socket. was
dening. ther incident. The tibial fracture was
Physical examination revealed a not affected by the fall; however, it au°'
rather bulbous ankle disarticulation healed with a slightly larger medial knet
dom require physical therapy and
amputation with full-width mediolat- bow tl1an the contralateral limb. On ter J
rarely require hospitalization for
rem,
prosthetic gait traini ng. 10 eral malleoli. The distal heel pad was presentation, the residual limb was
very stable and had slight abrasions well healed with a rather bulbous dis· eveJ
from ambulation without a prosthe- tal segment as a result of preservation dela
Case Studies sis. He had good range of motion at of the medial and lateral aspects of men
Case Study 1 all joints proximal to the amputation. the maUeoli. A 2-cm area of adhered havt
A 60-year-old man who had been a After reviewing the alternatives tissue on the medial scar line had not
farm worker for nearly 35 years sus- with his prosthetist, the patient de- caused the patient any problems with
tained a trawnatic crush injury to his cided that the best option for him was prostl1esis use in the past.
left forefoot after a 3,000-lb paper roll a prosthesis with a medial door and The patient was an ex'tremely ac·
landed on his foot. After the accident, straps to eliminate the bulk above the tive young man who liked to partici·
he underwent multiple procedures, ankle that an insert or bladder type pate in various sports, especially ten·
including toe amputations, metatarsal would require. The prosthesis was de- nis and basketball. He weighed 200 lb,
ampu tations, neuroma resections, signed to maintain some proximal was in excellent physical condition,
and a spinal nerve stimulator for weight bearing but took full advan- and was not taking any medications.
pain. Despite these procedures, he tage of his end-bearing tolerance. Because strength of the prosthesis was
continued to have severe pain and hy- The patient was fitted with his a primary concern in this case, a
peresthesia suggestive of complex re- prosthesis. On 1-week follow-up, the bladder-type prosthesis was recom·
gional pain syndrome. The patient patient ambulated with only one mended. The socket was designed in·
underwent an elective ankle disarticu- crutch for security and could ambu- corporating an expanded polyethyl·
lation approximately 5 years after the late without an assistive device. He ene foam liner for ease of donning
initial injury. Following debridement had no discomfort during ambula- and adjustability. Tbe socket was

ed
rnade of carbon fiber throughout with Summary and 6. Iuliucci L, DeGaetano R (eds): VAPC
an increase in laminate thickness Technique for Fabricating a Plastic Syme
·e- Conclusions
around the anterior wall to help re- Prosthesis with Medial Opening: Fabri-
110
duce the possibility of structural fail- When fitting an ankle disarticulation cation Manual. New York, NY, Pros-
:a- thetics and Orthotics, New York Uni-
ras
ure from compression forces during prosthesis, a thorough understanding
versity Post-Graduate Medical School,
:is. jumping and running. The design of of the mechanics of the socket, limb, 1969.
the device a!Jowed some weight bear- and gait is important. Patients often
ch 7. Cottrell-fkerd V, Ikerd F, Jenkins DW:
ing arotmd the distal end; however, request a lower profile socket, but this
an The Syme's amputation: A correlation
careful modification of the tibial shaft compromises the gait pattern and
ilis of surgical technique and prosthetic
and proximal anterior contours were
nb comfort. Despite the limitations in management with an historical per-
necessary to permit high-impact ac- spective. J Foot Ankle Surg 1994;33:
cosmetic appearance and ankle-foot
tivities. Further relief around the area 355-364.
options associated with ankle disar-
of adhered tissue was requfred, as was 8. Perry J: Gait Analysis, Normal and
ticulation prostheses, the ankle disar-
,en careful contour of the posterior distal Pathological Function. New York, NY,
ticulation is a very functional level of
aspect of the distal socket to prevent McGraw-Hill Inc, 1992, pp 9-47.
red amputation.
tension over the adhered tissue. In- 9. Pinzur MS, WolfB, Havey RM: Walk-
.cal
:ci- creased proximal weight bearing was ing pattern of midfoot and ankle dis-
lOn
needed in addition to the conservative References articulation amputees. Poot Ankle Int
distal modifications. A carbon-fiber 1997; 18:635-638.
hat l. Marks GE (ed ): Manual ofArtificial
dynamic-response foot, custom-made Limbs: An Exhaustive Exposition of I 0. Pinzur MS: Restoration of walking
.Ost
,re- for the patient's weight, limb length, Prosthesis. New York, NY, AA Marks, ability with Syme's ankle disarticu1a-
and activity level, was placed on the 1907, p 37. tion. Clin Orthop 1999;361:71-75.
me
)ial prosthesis. This foot was attached to 2. Berke GM: Amputations and prosthe- 11. Waters RL: T he energy expenditure of
the posterior wall of the socket with amputee gait, in Bowker JH, Michael
.g a ses of the foot and ankle: Partial foot
carbon fiber and allowed a natmal JW (eds): Atlas of Limb Prosthetics:
iis- prostheses, in Coughlin MJ, Mann RA
gait pattern as well as enabling high Surgica~ Prosthetic, and Rehabilitation
the (eds): Surgery of the Foot and Ankle, ed
activity function. The foot was placed Principles, ed 2. Rosemont, IL, Ameri-
lual 7. St. Louis, MO, Mosby, 1999, vol 2,
can Academy of Orthopaedic Sur-
·ox- as laterally as possible on the socket pp 995-1006. geons, 2002, pp 381-387. (OriginaUy
fhe because of the increase in tibial bow- 3. Pritham CH: The Syme prosthesis, in published by Mosby-Year Book, 1992.)
nding and was placed in a slight valgus Murdoch G, Donovan RG (eds): Am-
12. Waters RL, Perry J, Antonelli D, Hislop
fur- position so that at midstance the foot putation Surgery and Lower Limb Pros- H: Energy cost of walking of ampu-
was was flat on the floor. This positioning thetics. Oxford, England, Blackwell tees: The influence of level of amputa-
r, it allowed for a slight varus thrust at the Scientific Publications, 1988, tion. J Bone Joint Surg Am 1976;58:
dial knee during single-limb support. Af- pp 87-93. 42-46.
On ter 1 year of use, the liner and socket 4. Radcliffe CW: The biomechanics of 13. Pinzur MS, Littooy F, Daniels J, et al:
was remained in excellent condition; how- the Syme prosthesis. Artif Limbs 1961; Multi.disciplinary preoperative assess-
dis- ever, the prosthetic foot had become 6:76-85. ment and late function in dysvascu lar
tion delam inated and required replace- 5. LeBlanc MA: Elastic-liner type of amputees. Clin Orthop 1992;281:
s of ment. No other prosthetic problems Syme prosthesis: Basic procedure and 239-243.
ered
have been noted. variations. Artif Limbs 1971;15:22-26.
not
with
ac-
tici-
ten-
O lb,
tion,
lOnS.
; was
;e, a
:orn-
:i in-
thyl-
,ning
was

In·
Am
low
tibi
Ma
twc
tra1
tra:i
lev(
can
Thi
joi.J.
cor
tra1
tivt
wit
sev
Co
19,
rat
73.
co,
th(
to
of
pei
rec
Fl(
tw.
cu
di,
65
tat
de
an
tw
biJ
wi
tr.
Transtibial Amputation:
Surgical Management
John H. Bowker, MD
Introduction
Among major amputations in the cessfully fitted with a prosthesis. In the 28 persons whose only injury
lower limb, amputations at the trans- There was no significant difference was the amputation, SF-36 scores
tibial level are the most common. between the two groups in fitting suc- were close to those of age- and sex-
Many series repor t a ratio of at least cess over the 40-year span, although matched controls. In contrast, the 44
two transtibial amputations to every significantly more transtibial amputa- amputees who sustained additional
transfemoral amputation. 1- 6 The tions were performed in the later co- major injuries had significantly lower
transtibial level is the most proximal hort.25 scores, and many required psycholog-
level at which near-normal function In contrast to these elderly pa- ical help.
can be expected for most patients. tients, Purry and Hannon 26 made a Another singular advantage of
This is because preserving the knee detailed study of 25 unilateral ampu- transtibial over transfemoral amputa-
joint allows transtibial amputees to tees younger than 45 years at the time tion is markedly reduced periopera-
consume much less energy th an of amputation who had undergone tive mortality. In three studies 1• 10•16
transfemoral amputees.7 -9 The rela- transtibial amputation because of the combined mortality associated
tive ease of transtibial gait compared trauma. They were followed up at 2.5 with transtibial amputation was 9.5%
with transfemoral gait is borne out by years after surgery to assess function compared with 29.7% for transfemo-
several studies of prosthesis use. and lifestyle. Of the 25 patients, 21 ral amputation. Sarmiento and War-
Combined data from 13 studies from (84%) wore the prosthesis more than ren28 reported virtually the same
1943 through 1983 show an average 13 hours a day, 18 (72%) could walk 6ndings. They noted a decrease in
rate of transtibial prosthesis use of 1 mile if necessary, and 2 1 (84%) mortality rate from 24% to 10% that
73.5%. 10- 22 Analysis of four studies drove an automobile. Eighteen (72%) they related directly to the reversal of
covering the same period shows pros- played sports. The most notable find- their transtibial-to-transfemoral am-
thesis use by transfemoral amputees ing was that 21 (84%) of these unilat- putation ratio from 1:2 to 2:1.
to average only 26.5%. 10•11 •23•24 Most eral transtibial amputees regarded For many years, transfemoral am-
of the patients in these studies had themselves as minimally disabled or putations were preferred to transtibial
peripheral vascular disease. A more nondisabled. 26 amputations because primary healing
recent retrospective review by In 2001, Dougherty27 reported a was thought to be easier at the thigh
Fletcher and associates 25 compared 28-year folJow-up of 72 unilateral level. Healing at that level, however, is
two local cohorts of m1ilateral dysvas- transtibial amputees who had been far from certain. In a series of 171
cular amputees, of whom 49% had injured by land mines or booby traps amputations, Boontje 1 noted a 28%
diabetes mellitus. All were older than during the Vietnan1 war. The Medical failure of transfemoral healing, com-
65 years, with a median age at ampu- Outcomes Survey Health Status Pro- pared with 35% for transtibial ampu-
tation of 79 years. The first group un- file (MOS SF-36) is a 36-item self- tations. Pooling the data from eight
derwent amputations between 1956 report functional outcomes instru- reported series totaling 942 cases,
and 1973, and the second group be- ment describing physical functioning, each with at least 50 patients, showed
tween 1974 and 1995. Of the com- role limitations due to physical and that 70% of trans tibial amputations
bined 292 patients, only 78 (47%) emotional problems, social function - healed primarily and 16% second-
with a transtibial and 15 (13%) with a ing, general mental health, pain, arily, for a total healing rate of
transfemoral amputation were sue- health perception, energy, and fatigue. 85%. 13,29 - 35 These series did not sepa-

rate patients with diabetes mellitus style and elderly patients the oppor- The population of patients with leg, a
who may or may not have had is- tunity to walk rather than be confined diabetes is growing rapidly, but it is shoul
chemia from patients with ischemic to a wheelchair. Because the risk of unclear whether this is because of destn
disease alone. Allcock and Jain 36 re- later contralateral amputation is high, earlier detection, increased longevity that I
ported on 395 transtibial amputations every effort should be made to pre- because of better treatment, popula- ampu
performed using the Burgess tech- serve at least a transtibial level at the tion growth, or other factors . It is cer- tion,
nique between 1987 and 1996. They first amputation and provide preven- tain, however, that an increasing per- foot I
found that 80% healed primarily, 3% tive care for the opposite foot over the centage of lower limb amputations is 6 hot
secondarily, and 13% after local long term . being done in these patients. For ex- jury .
wedge resection of a dehisced wound, ample, a 1956 study showed diabetes putat
for a success rate of 96%. Only 4% reas a factor in only 16% of lower limb w
quired revision to a transfemoral
Causal Conditions amputations. 33 In contras~, combined has r,
level. Diabetes Mellitus data from 17 studies published be- becat
Primary amputation at the trans- With aging of the population, trauma tween 1961 and 1988 showed that in or pe
femoraJ level was long recommended has been replaced by peripheral vas- an average of 52% of patients (range, putat
for patients with diabetes because of cular disease with or without diabetes 30% to 75%), diabetes mellitus was (Figu
the supposed unlikelihood of healing as the leading cause of lower limb the primary or secondary cause of done
at more distal levels in these patients. amputation in developed countries. amputation. 1,3, t3, l4, J 7, t9-2l,23,29,37,4S-so that
Data were combined from four series Smoking appears to be related to this little
to compare the healing rate of trans- increase.40 In a review of 51 male Infection proa,
tibial amputations in patients with di- lower limb amputees in the United In Hansen's disease (leprosy), infec- and<
abetes with that in patients with Kingdom, Stewart41 found a signifi- tion of peripheral nerves with Myco- Iidisr
purely ischernic disease. Among 194 cantly higher rate of amputation in bacterium leprae causes foot insensi- shou
patients with diabetes, wounds healed smokers (82.4%) than in the general tivity. Progressive loss of bone and amp1
in 92% . In con trast, wounds healed in population (55%). In another series, soft tissues, aggravated by intractable sona
only 75% of 188 patients with purely 58% of 110 transtibial amputees were deep infection following skin ulcer- bula1
ischemic disease.4' 16'21 •37 The authors smokers. 42 The precipitating cause of ation, may require transtibial ampu-
of two additional series, each with amputation may be gangrene, infec- tation. Severe tissue destruction from
tion, or intractable claudication. 1 In fungal infection may occur in the
Co
100 patients with diabetes, reported
transtibial healing rates of 99% and diabetes mellitus, most amputations presence of normal sensation, as in Seve
90%.2•15 These studies strongly sug- are related to various types of foot in- mycetoma, or "Madura foot." Other trailll
gest the fallacy of the old notion that jury secondary to peripheral sensory major infections that may result in tion
the best treatment of foot lesions in neuropathy, often with minor foot lower limb amputation include vase
patients with diabetes is primary damage providing a portal for infec- chronic osteomyelitis and life- tion
transfemoral amputation. tion. Infection in patien ts with diabe- threatening forms of infectious gan- is ai
In ischemic conditions, unilateral tes may be difficult to combat at the grene, including clostridial myone- vere
transtibial amputation may be fol- tissue level because of decreased leu- crosis (gas gangrene) and necrotizing in t
lowed by loss of the opposite limb as kocyte activity in the byperglycemic fasciitis. may
vascular disease progresses. One study state.43 Patients with diabetes often tran
of 80 patients noted an average inter- continue to walk on infected feet be- with
val of 23 months between transtibial cause they have lost deep pain sensa-
Indications eno1
amputations. 38 The risk of contralat- tion, thereby rapidly spreading in- In general, transtibial amputation is pro~
eral Limb loss is 10% per year. 3 With fected fluids along tissue planes. indicated whenever the initiating dis- knee
sufficient longevity, therefore, most Charcot neuroarthropatl1y, which can ease or trauma cannot be treated ef- the
transtibial amputees will face the begin with minor trauma, may also fectively by more conservative pro- tive
prospect of loss of the opposite lower lead to amputation if the bones of the cedures. In cases of severe foot ami
limb, and ambulation as a bilateral foot and ankle become severely dam- infection, usually related to diabetes tory
transtibial amputee thus becomes of aged. Although atheromatous disease mellitus, much of the tibia can usually tain
major concern. Pooled data on 137 often develops in patients with diabe- be spared even if the proximal spread liml
patients showed that 77% of bilateral tes at an earlier age than in the gen- of infection precludes a partial foot wh~
transtibial amputees were able to ateral population, it may be difficult to amputation or Syme ankle disarticu- relu
tain functional ambulation.21 '24 ' 38' 39 determine the relative importance of lation. In peripheral vascular disease aml
In summary, the importance of occlusive changes seen in larger ves- with distal gangrene, transtibial am- stri,
preserving the knee joint cannot be sels and more peripheral small-vessel putation is suitable if the level se- trac
overemphasized. It allows younger disease in the causation of gan- lected has enough vasculature. In ing
patients to continue a vigorous life- grene.44 cases of trauma to the foot and lower cho

Chapter 38: Transtibial Amputation: Surgical Management 483
ith leg, an initial transtibial amputation Several conditions are m istakenly

: is should be done if there is such severe thought of as relative contraindica-
of destruction of soft tissue and bone tions to transtibial amputation.
'ity that reconstruction or a more distal Patients with diabetes or Hansen's dis-
Lla- amputation is not feasible. In addi- ease need not be denied a transtibial-
:ertion , if warm ischemia of the leg and level amputation based on insensate
1er- foot has been present for more than skin. With good prosthetic fitting and
s is 6 hours following severe vascular in- regular observation of the skin for ar-
ex- jury to the lower limb, primary am- eas of pressure, the transtibial ampu-
!tes putation should be considered.5 1 tee should do well long term. Even
rob When reconstruction after trauma some patients with hemiparesis on
n.ed has resulted in an tmsatisfactory limb the amputated side can accomplish
be- because of deformity, pain, nonuni.on, household ambulation with a trans-
t in or persistent infection, transtibial am- tibial prosthesis. Poor knee control
1ge, putation is usually a good solution can often be managed with a hybrid
was (Figure 1). The amputation should be "prosthosis" that combines a transtib-
of done as soon as it becomes apparent ia1 prosthesis with orthotic knee-
,-so that further attempts at salvage have control components, provided that
little likelihood of success. This ap- tlexion or extension patterning is not
proach can spare the patient expense extreme and that reasonable balance
fec- and distress and prevent chronic inva- is present. Patients who are able to Figure 1 This 28-year-old man had
yco- lidism. Finally, transtibial amputation comprehend and follow instructions chronic infected nonunion of the right
t ibia. He requested transtibial amputa-
nsi- should be favored over transfemoral can do quite well with a prosthesis. If
t ion 13 months after injury w hen it be-
and amputation whenever there is a rea- patterning is extreme or if a knee tlex- came apparent t hat f urther attempts at
able sonable possibility of prosthetic am- ion contracture is significant, a knee limb salvage would be futile.
.cer- bulation. disarticulation should be considered,
1pu- provided that hip control is present.
Even if patients are not candidates tory to assess possible injuries to
rom
the
Contraindications for prostheses, sitting and kneeling other areas.
s in Several absolute and relative con- will be enhanced by salvaging as When peripheral vascular disease
ither traindications to transtibial amputa- much of the leg as possible. with or without diabetes mellitus
It in tion should be recognized. Inadequate Children with congenital foot leads to amputation, the presence of
lude vascularity for any reason at amputa- anomalies requiring revision to allow associated diseases must be assumed.
life- tion sites between the knee and ankle use of a prosthesis are not well served Barber and associates 10 fow1d that 53
gan- is an absolute contraindication. Se- by transtibial amputation because it of 70 patients (76%) coming to trans-
one- vere rest pain or gangrenous changes will interfere with the growth of the tibial amputation had degenerative
izing in the proximal portion of the calf residual limb and make its relative diseases in addition to the primary
may indicate the need for a primary length much less tl1an ideal in adult- disease that necessitated the amputa-
transfemoral amputation. A patient hood. In these cases, disarticulation at tion. Special attention must be di-
with a knee flexion contractm·e severe the ankle joint, without disturbing rected to prompt and rapid preopera-
enough to prevent use of a tnnstibial the physis, will preserve end- weight- tive control of congestive heart
)n is prosthesis may be best served by a bearing capability and also allow a failure, arrhythmias, electrolyte im-
; dis- knee disarticulation, provided that moderate increase in length over balance, dehydration, hypertension,
d ef- the skin at that level is viable. A rela- time. bronchitis, and diabetes. 2 0,41.
pro- tive contraindication to transtilbial When diabetes mellitus- related in-
foot amputation is prolonged nonambula- fection has led to the need for ampu-
betes tor y status, although Persson34 main-
Preoperative Care tation, serum glucose control will
;ually tains that the tibial poi-tion of the Several important factors must be usually be markedly disrupted. Be-
pread limb can still be useful in transfer and considered in the preoperative man- cause the treatment of infection and
foot wheelchair sitting activities, and he is agement of prospective amputees, of hyperglycemia are interdependent,
rticu- reluctant to remove it based on non- largely related to the reason for am- they must be approached simulta-
isease ambulation alone. If the patient is putation. For example, patients un- neously for optimum effect. Follow-
l arn- strictly bedbound, a knee tlexion con- dergoing amputation for trauma of- ing initial aerobic and anaerobic
~l se· tracture will very likely develop, mak- ten have concomitant injm·ies to wound cultures, broad-spectrum an-
e. In ing knee disarticulation a good other bones, soft tissue, or viscera. A tibiotic therapy should be started,
lower choice. ca1·eful evaluation is therefore manda- pending bacterial sensitivity studies.

tient compliance, which can lead to a the I

better su rgical outcome. The surgeon vice:
should give the patient a reasonably amp
detailed account of the process, in- crea
cluding the need for amputation, the per
proposed level and its implications, 199(
and the stages of prosthetic rehabili- in p
tation.48·60 The surgeon should dun
strongly discourage smoking periop- for'
eratively and postoperatively, as re- ated
fraining from smoking will promote mus
wound healing.20 A Danish study stud
showed 50% h igher wound infection tran
and reamputation rates in lower limb faile
amputees who continued to smoke Van
Figure 2 Right leg of man with chronic osteomyelit is of t he tibia for 46 years after cigarettes before, during, and after duci
t rauma. Squamous cell carcinoma had developed in t he constantly draining sinus. There hospitalization for amputation sur- 234
were no enlarged inguinal lymph nodes. A short transtibial amputation was performed gery. The investigators recommended forn
and was curative. smoking cessation l week before sur- twe<
gery, continuing throughout wound aim
Care should be taken to avoid neph - of wound heal ing potential are also healing. 61 wh<:
The physical therapist and pros- byp
rotoxic drugs whenever possible. If indicated. These include a serum al-
thetist should also meet with the pa- thoi
these drugs are needed, renal function bwnin level of at least 3.0 g/dL as an
tient preoperatively to outline their am1
should be closely monitored. indicator of adequate nutrition and a
roles. A psychologist experienced in tot
Icing of a necrotic or infected limb total lymphocyte count of at least
treating amputees can encourage pa- follc
to control local and systemic effects of l,500/mm 3 as a measure of irnmuno-
tients to express their anxieties re- pan
the infection is rarely, if ever, used to- competence. If these values are abnor-
garding both the surgical and pros- tion
day. Its use in selected cases had been mal, difficulties with primary wound
thetic phases of care. A preoperative call:
suggested in the past by Kendrick, 33 healing may be expected.55·56 autl
visit by a trained amputee peer coun-
but Pedersen and associates 52 have Adequate nutritional support to
sur~
selor matched with the patient by age,
condemned this practice because after reverse the catabolic state associated trar.
sex, and level of amputation can also
icing, they believe, a transfemoral am- •Nith infection and bed rest should be-
be very beneficial. ho"'
putation is unavoidable. Instead, they gin preoperatively, preferably by oral whc
advocate prompt drainage of ab- intake. Nu tritional supplements such ble,
scesses, followed by appropriate anti- as multivitamins, ascorbic acid, zinc, Level Selection maa
biotics and bed rest. 52 and ferrous sulfate provide essential Level selection should be highly in di- pot1
In patients with diabetes, a wide elements for collagen formation in vidualized. With tumor surgery, suq
range of bacteria may be associated wound healing. 57•58 Significant caloric achieving adequate margins free of tio:r.
with foot infections, including gram- enhancement will require corre- disease must be the surgeon's firs t <let<
positive, gram-negative, aerobic, and sponding increases in hypoglycemic concern, with preservation of limb am1
anaerobic organisms, occasionally oc- agents to prevent iatrogenic hypergly- length a secondary goal (Figure 2). of
curring singly but more often in vari- cemia. With amputation after tra uma, the pad
ous combinations.53•54 Hoar and If time and the patient's condition length of reconstructible tissue distal In (
Torres 15 found Staphylococcus aureus, allow, patients should be introduced to the knee is us ually determined by ma]
Streptococcus hemolyticus, and Proteus to the team members who wiH be car- the accident and previous treatment. pla1
vulgaris to be most common. Fearon ing for them postoperatively. The In dysvascular patients, the SLU'geon trar
and associates 2 cultured more than 15 physical therapist can start a whole- should first determine if the limb can ank
different bacteria in a series of pa- body conditioning program preoper- be salvaged by reconstructive vascular rul!t
tients with diabetes-related gangrene. atively to prevent contractme of the surgery, either entirely or with only the
Systemic infection secondary to wet hip and knee on the side of the ampu- partial loss of the foot. Consultation ticu
gangrene or infections independent of tated limb and teach safe ambulation with the vascular surgeon has become par
the foot must also be controlled pre- with a walker or crutches.29•59 increasingly important as vessel by- to I
operatively. Specifically, evidence of Because the patient looks to the pass and recanalization techniques
62
genitourinary and pulmonary infec- surgeon for guidance, the surgeon has have evolved. Ebskov and associates fact
tions should be sought. Assessments a unique opportunity to i11fluence pa- found an inverse correlation between ove

a the rate at which vascular surgery ser- success or failure solely on one crite- ulcers, tissue necrosis, gross infection,
vices were used and the incidence of rion. Although both clinical evalua- or lym phangitis. 1.2. 12, 16,19,29,30,31,s2 All-
111
ly amputations for dysvascularity. A de- tion and objective laboratory cock and Jain36 found that a skin tem-
1- crease in amputations from 34.5 to 25 measurements of vascu1arity are rea- perature above 30.4°C at the proposed
le per 100,000 popttlation from 1983 to sonably predictive of success or failure site of a long posterior transtibial flap
lS, 1990 coincided with a 100% increase at both the high and low ends of mea- correlated well with primary healing.
li- in peripheral vascular smgery proce- surement spectra, an intermediate If peripheral pulses can be easily
ld dures. Nonetheless, the enthusiasm gray zone of unpredictability always felt, they can be assumed to be
p- for vascular salvage procedures gener- remains. The best cluster of tests for present. If the pulses cannot be felt,
·e- ated by the high overall success rate level selection, which does not yet ex- however, they may still be present but
,te must be tempered by comparative ist, wou1d be that which predicts fail - obscured by edema, hypotension, or
dy st udies showing a higher rate of ure with 100% accuracy and thus obesity. A significant number of trans-
)11 transfemoral amputation following guides the surgeon away from that lev- tibial amputations will heal despite
nb failed infrainguinal bypass surgery. el. 66•67 This would avoid amputation the absence of palpable pulsation at
ke Van Niekerk and associates63 con- at higher levels in patients who could any given site, including the superfi-
ter ducted a prospective cohort study of heal at the transtibial level but were cial femoral level. In a series of 113
1r- 234 amputations in 219 patients per- excluded from transtibial amputation transtibial amputations, 2 1 64 (57%)
.ed fo rmed for critical limb ischernia be- by overly strict application of criteria healed with only an aortic pulse
lf- tween 1994 and 1996. Patients were that include a built-in fai lure rate for present; the addition of a femoral
nd almost equally divided between those reasons that are not determined by the pulse increased the success rate to
who had first undergone ipsilateral study method. Until an infallible lab- 81 %. When popliteal or pedal pulses
:>S- bypass surgery for limb salvage and oratory evaluation exists, surgeons were palpable, all the amputations
)a- those who had undergone primary should evaluate preoperatively factors healed. Combined data from six stud-
.eir amputation. The ratio of transtibial other than tissue blood flow, such as ies on the relationship of healing rate
111 to transfemoral amputation was 2.05 poor nutritional status, tissue glycosy- to the presence of a palpable popliteal
pa- following failed bypass surgery, com- lation secondary to chronic hypergly- pulse indicate that although 65% of
re- pared with 5.05 for primary amputa- cemia, and infection. When failure oc- these patients had no palpable
os- tion at the indicated level, a statisti- curs nonetheless, suboptimal surgical popliteal pulse, 82.5% healed at the
ive cally significant difference. These technique or poor postoperative transtibial level. 10 - 13 •47•68 These find-
11n- authors concluded that failed bypass wotmd management may be the cause. ings point out the difficu1ty in evalua-
1ge, surgery prejudices preservation of the The more traditional methods of tion of collateral circulation by palpa-
tlso transtibial level. They were unable, level selection are considered in this tion. The profunda femoral artery,
however, to identify those patients in cl1apter. For a detailed discussion of which may be the only major vessel
whom amputation wou1d be inevita- laboratory tests designed to give more providing collaterals to the calf, is, of
ble, indicating the advisability of pri- objective measurements of limb and course, inaccessible to the palpating
mary amputation to avoid a futile and tissue blood flow, refer to chapter 3. finger. 46 •69 Arteriography has been
1di- potentially harmful attempt at bypass In practice, level selection by either found to correlate as poorly with the
ery, surgery. 63 •64 If vascular reconstruc- approach remains somewhat idiosyn- healing potential of transtibial ampu-
of tion is not feasible, it should then be cratic and is based on the attitudes tations as do palpable pu1ses. 34 Arteri-
first determined what length of trnnstibial and prejudices of the surgeon as well ography is now used chiefly to deter-
imb amputation has a reasonable chance as those of the prosthetist regarding mine the feasibility of vascu1ar
2). of healing while providing a well- the level under consideration. This is reconstruction. 10
the padded, durable soft-tissue envelope. attested to by the varying ratios of Many surgeons have relied on the
istal In cases of foot infection, the proxi- transtibial to transfemoral amputa- trial skin incision to decide at which
l by mal extent of infection along tissue tions performed in similar institu- level to amputate. 11 •70•71 The pre-
1ent. planes may determine whether a ray, tions in different parts of the world smnption is that if the skin bleeds
;eon transmetatarsal amputation, or Syme and even in various parts of the same within 3 minutes after incision at the
can ankle disarticulation is feasible. If pu- country or city. proposed level, it shou1d heal at
:ular rulence has extended proximally to Even with the development of more that level; if the skin does not bleed,
only the ankle, an injtial open ankle disar- sophisticated tests, most surgeons the surgeon should immediately
tion ticulation with fasciotomies and com- continue to rely on factors that can move proximally. Kendrick,33 how-
ome partmental debridement is indicated be easily evaluated by touch and ever, noted no correlation between
by- to preserve length.65 sight, including peripheral pulses, skin bleeding of a trial skin incision and
ques Although level selection is mu1ti- warmth and texture, color of the foot healing potential. Also, the basic ques-
tes62 factorial, many studies have tried to when dependent and elevated, hair tion of how distally the initial trial
.veen oversimplify the problem by basing growth, and the presence of indolent skin incision should be made remains

In summary, there is no longer an Geri

ideal length or site of amputation. In In a
dysvascular patients with an absent putat
popliteal pulse, amputation in the sia c,
Very short
proxi ma! half of the leg seems reason- the p
able, with a bony level as distal as the cardi
junction of the proximal and middle it m~
Short
thirds. In patients with good blood
flow to the ankle, bone length at the
Medium
junction of the middle and distal SUI
thirds results in a strong lever arm Amp
and a broad interface with the pros- sider
thetic socket, providing better distri- usele
Long
bution of body weight during stance
)
rec01
and improved suspension of the pros- res to
thesis during swing. Modern pros- ti.on.
Figure 4 Lateral radiograph of a non- thetic components can be easily
functio nal transtibial amputation trans-
tram
ected proximal to the tibial tubercle. To
matched to these more distal levels. surg:
preserve active knee extension, the tibial ope<
tubercle and patellar tendon must be el.76
saved. Anesthesia
Figure 3 Levels of transtibial amputa- the :
tion. At the "very short" level, the fibu lar Various types of anesthesia are useful to d
head is excised and the peroneal nerve is
gins to taper beyond that point. Mars- in transtibial amputation. The choice mat(
shortened. With sufficient vascularity and depends on the patient's condition,
den72 recommends limiting the i11te1
myodesis of the soleus to bone, preserva-
the skills and experience of the anes- achi,
tion of two thirds to three quarters of length to 15 cm on the presumption
tibial length can resu lt in a very func- thetist, and, to the extent these factors be~
that this length will be easier to fit
tional residua l limb. (Adapted with per- allow, the patient's choice. by (
with a prosthesis.
mission from Epps CH: Amputation of the perf.
lower limb, in Evarts CM (ed): Surgery of Over several decades, several au- Local Anesthesia
thors have cast doubt on this certi- exp€
the Musculoskeletal System, ed 2. New
An extremely ill or even moribund thig
York, Churchill Livingstone Inc, 1990.) tude. Harris, 73 although recommend-
patient can undergo a transtibial am- case
ing a short transtibial amputation in
putation without pain under local an- dys"
unaddressed. A distal trial incision his article of 1944, noted that a long
esthesia. The agent is injected along be ~
that bleeds, however, should encour- transtibial amputation is stronger the proposed incision line with sbo1
age the surgeon to proceed at that than a short one. Despite this recog- deeper tissues infiltrated as necessary. proI
level. nized functional advantage, he rec- Nerves, especially the tibial nerve, are 1
Once the decision has been made ommended a short residual limb be- individually injected before any ma- mar
to amputate at the transtibial level, cause of the skin complications seen nipulation and section. Agents con- liml
the equally important choice m ust be in longer amputations from wearing taining epinephrine should be pro1
made as to the exact length to be re- the prostheses with the plug-fit sock- avoided. and
tained (Figure 3) . The shortest useful ets and thigh corsets that were avail- pro1
residual limb must include the tibial able at that time. Moore 69 stated that Regional Ar.iesthesia suei
tubercle, to preserve knee extension the greatest length compatible with For patients with severe cardiopulmo- mer
by the quadriceps 16 (Figure 4). Flex- healing should be retained, whereas nary compromise, a sciatic-femoral be
ion at this level is provided by the Epps 74 stated that the basic rule was block can be very effective. It can be sect
semimembranosus and biceps femo- to save all length possible, correlating supplemented, if necessary, with a lo- leve
ris. Beyond this basic universal agree- it to function and the prosthetic com- cal anesthetic agent. ho.ill
ment as to the shortest possible func- ponents to be used. McCollough and avo
tional level, the ideal length for associates 75 did not specify an opti- Low Spinal Anesthesia dan
optimal prosthetic function has not mal length but flatly stated that the Low spinal anesthesia has little effect cise
been determined. The amputation longer the residual limb, the better on the pulmonary system. Control of flai;
method advocated by Burgess,7 1 the gait. This position is supported by blood pressure, however, can be prob· cisi,
which results in a cylindrical residual work showing that transtibiaJ ampu- lematic. If hypotension occurs, it as t
limb, effectively limits length to ap- tees v.rith longer limbs require less en- should be corrected with fluid admin· to
proximately 15 cm because the leg be- ergy to ambulate.8 istration and/or vasopressors. am-

an General Anesthesia
TABLE 1 Types of Transtibial Amputations
In In a healthy patient undergoing am-
mt putation for trauma, general anesthe- Closed Amputations Open Amputations
:he sia can be quite safe and effective. If Long posterior myofasciocutaneous f lap Guillotine
>U- the patient has severely compromised Equal anterior and posterior f laps Open circumferential
the cardiopulmonary function, however, Equal medial and lateral (sagittal) flaps Open f lap(s)
dle it may not be the best choice. Skew sagittal flaps
,od Medial flap
the End-weight-bearing amputations
Stal
Surgical Technique Distal tibiofibular synostosis
Foot fillet
liffi Amputation should no longer be con-
·os- sidered as purely the ablation of a
tri- useless or debilitating part, but also a
nee reconstructive procedure designed to
ros- restore optimum ambulatory func-
ros- tion. As more functional goals for the
1sily transtibial amputee are realized, new
s. surgical techniques have been devel-
oped to enhance function at that lev-
el.76 To achieve optimum function,
the surgeon must be willing at times
;eful to do staged procedures.65 The ulti-
.oice mate goal is a residual limb that will
jon, interface well with a prosthesis. To
nes- achieve this, the amputation should
:tors be performed or directly supervised
by an experienced surgeon and not
performed tmsupervised by the least
experienced surgeon in training. A
)Und thigh tourniquet is recommended in
am- cases of amputation for trauma. l n
1 an- dysvascular cases, a tourniquet may
tlong be put in place but inflated for only a
with short period of time if bleeding is
,sary. problematic during surgery.
e, are There are two criteria for the pri-
ma- mary healing of transtibial residual
con- limbs. First, as discussed above, is
be proper selection of level. A second
and equally important criterion is the Figure 5 Amputations using the long posterior myofasciocutaneous flap technique.
proper technical management of tis- A, This 15-year-old boy underwent right transt ibial amputation fo llowing severe foot
sues during the procedure. The place- trauma sustained in a motorcycle accident. Three quarters of the tibial length was re-
tained, with distal padding provided by myodesis of the soleus to bone. The patient be-
1lmo- ment and measurement of flaps must came an expert wrestler and handball player, and, eventually, a prosthetist. B, This 58-
moral be accurately related to the cross- year-old man with diabetes underwent a transtibial amputation for ischemic gangrene
:an be sectional area of the leg at the bony of the foot. Two thirds of t he tibial length was retained. Three years later, t he right
i a lo- level selected. Otherwise, either the lower limb was amputated at the same level. The man remains an excellent walker w it h
bone will need to be shortened to prostheses, using one cane for balance.
avoid closure under tension or redtm-

dant soft tissue will have to be ex-
effect cised. Successful use of a variety of Closed Amputations ous flap in 110 transtibial amputa-
trol of flap configurations has shown that in- tions. The educational efforts of Bur-
long Posterior gess,71 however, were the major
prob- cision placement is not crucial so long
as the incisional scar does not adhere Myofasciocutaneous Flap impetus for the acceptance of this
us, it
1dmin- to the underlying bone. Transtibial In 1943, Bickel 11 reported on the use concept (Figure 5). Provided that vas-
amputations are listed in Table 1. of a long posterior myofasciocutane- cular perfusion is adequate, a poste-

Figure 7 lntraoperative view of a long

transtibial amputati on. The superf icial Correct Incorrect
peroneal nerve is found in the sulcus be- (tapered) (conical)
tween the anterior and lateral compart- FigL
ment muscles. It will be transected under Figure 8 A natura lly tapered residual tra11
slight tension. limb resu lts from cutting the fibula only und
minimally shorter t han the tibia. If the ture
fibula is cut too short, both the distal sum
Figure 6 Long posterior myofasciocuta- tibia and t he distal fibula become unduly tibi,
neous f lap technique. A, Schematic dia- prominent and subject to painful pres-
gram showing skin incision for very short sure from the prosthetic socket. (Adapted
anterior and long posterior f laps for trans- with permission from Moore WS, Malone
tibial amputation. Point A is 1 cm distal JM (eds): Lower Extremity Amputation.
to bone section. The length AB is equal Philadelphia, WB Saunders, 1989.)
to two thirds t he diameter of the calf.
The length BC is equal to AB plus 1 cm.
(Adapted with permission from Wagner transected under slight tension, caus-
FW Jr: Resident Training Manual. Dow- ing them to retract into the soft tis-
ney, CA, Rancho Los Amigos Medical Cen-
ter.) B, lntraoperative view of a long tran-
sues (Figure 7). The anterior com-
stibial amputation. Note the very short partment muscles are carefully
anterior and long posterior flaps. The divided to expose the neurovascular
bone cut is made at the junction of the Figure 9 lntraoperative view of a long structures. The artery should be dou-
proximal two thirds and distal one t hird transtibial amputation. A long amputa-
bly ligated, the veins ligated, and the
of t he tibia in this patient with diabetes. tion knife is passed behind the tibia and
fibula and then distally along t he skin deep peroneal nerve cut under slight
edges to create a tapered posterior myo- tension. The tibia is stripped of peri-
rior myofasciocutaneous flap ca11 be fasciocutaneous f lap. osteum only to the level of transec-
formed down to the distal extent of tion to reduce the chance of bone
Fi91
the soleus muscle, with the technique spur formation. It is then cut trans- trar
length should be equal to the distance
becoming progressively easier in more versely witl1 a saline-cooled power bor
from the original reference point to
distal amputations. There are several saw or a Gigli saw. The fibula is ant ·
the anterior aspect of the tibia plus cleared with an elevator and cut ob- fibL
anatomic reasons for this. With distal 1 cm. As this line starts distally, it goes liquely with the power saw to form a are.
tapering of the calf, the cross- slightly anteriorly from the reference
sectional area of the leg decreases, re- facet facing posterolaterally. It should
point, and then gradually curves dis- be made equal to or slightly shorter ma
sulting in a short, widely based poste- tally around the posterior aspect of than the tibia to prevent undue distal lea:
rior flap with good perfusion . Distal the leg, where it meets a similar inci- tibial prominence, as seen in a coni- sap
muscle bulk is minimal with less tension from the opposite side. The small cal, ratl1er than a naturally tapered, rio.
dency for "dog ear" formation during medial and lateral half circles left at residual limb (Figure 8). A long am- sur
wound closure. My technique, the junction of the anterior and pos- putation knife is passed behind the a!lc
adapted from Wagner,9 involves first terior incisions elin1inate "dog ears" tibia and fibula and drawn distally to
marking reference points medially on closure (Figure 6) . create a tapered myofasciocutaneous cisc
and laterally on the leg at the junction The subcutaneous tissue and in- flap (Figure 9). The peroneal and pos- rio
of the anterior two thirds and poste- vesting fascia are cut in line with the terior tibial arteries are clamped, di- bu]
rior third of the leg diameter at the skin incision. At this point, the greater vided, and doubly ligated, and the red
level selected for bone section. Then, saphenous vein is ligated and its com- veins are singly ligated. The tibial pac
the two points are joined to form an panion saphenous nerve and the su- nerve may be ligated to secure its in- anc
anterior flap that is convex distally perficial peroneal nerve, lying later- trinsic vessels, then cut and allowed to tri1
and no more than 0.5 to LO cm long. ally in the sulcus between the anterior retract proximal to the bone end (Fig- Th
The posterior flap is then drawn. Its and lateral compartment muscles, are ure 10). Alternatively, these vessels cut

Chapter 38: Tr anstibial Amputation: Surgical Management 489
Figure 10 lntraoperative view of a long Figure 11 lntraoperative view of a long

dual transtibial amputation . The t ibial nerve is transtib ial amputation. The sura l nerve
only under slight tension as the suture liga· on th e left will be sharply divided under
' the ture is placed to secure t he vasa nervo- tension, and the lesser saphenous nerve
l istal sum before sharp d ivision. The posterior o n t he right will be ligated.
,duly tibial vessels are cl amped. Figure 12 lntraoperative view of a long
pres- transtibial amputation. Th e deep poste-
,p ted rior calf muscles have been excised, leav-
1/one ing the soleus as the only muscle in t he
1tion. posterior f lap. Myodesis of the soleus to
the drill holes, shown on either side of
the anterior cortical bevel, w ill provide
stable distal padding.
:aus-
t tis-
:om·
folly bevel. All bone detritus must be
cular washed carefully from the wound af-
dou- ter drilling. Following placement of
:i the an unsutured suction drain, the myo-
;light desis sutures are inserted. These su-
Figure 14 lntraoperative view of a long
peri- transtibial amputation. Reliable myodesis tures shoLtld be placed with minimal
nsec- is effected by sewing the soleus myofas- tension to avoid compromising blood
bone ci a and the posterior and anterior edges flow to the flap. The tissues join~d to
Figure 13 lntraoperative view of a long of the investing fascia to t he tibia the bone by tl1ese sutures include the
:rans- transtibial amputation. A f ine o ffset through two drill holes with heavy ab·
>ower bone file is used to smoothly contour the
anterior edge of the investing fascia,
sorbable sutures, as shown. The remai n-
tla is anterio r tibial corti cal bevel and distal der of t he soft t issues are closed by myo- the soleus in the case of a long trans-
It ob- fibu lar bevel to red uce potential pressure plasty. tibial amputation (or the gastrocne-
areas d uri ng prosthetic gait. mius in a short one), and the poste-
)fffi a
b.ould rior edge of the investing fascia
1orter may be cauterized lightly before re- tibia. All bone cuts are smoothly con- (Figure 14) . A heavy absorbable su-
distal leasing the cut nerve. The lesser toured with a bone file (Figure 13). ture works well for this. The medial
coni- saphenous vein is found in the poste- Transtibial wounds are best closed and lateral portions of investing fascia
Jered, rior flap and ligated, and the adjacent using a combination of myodesis and and muscles are sutured with irlter-
g am- sural nerve is cut under tension and myoplasty techniques. Myodesis pro- rupted absorbable suture in a myo-
.d the allowed to retract (Figure 11 ). vides firm fixation of the posterior plasty technique. No subcutaneous
illy to The deep calf musculature is ex- muscle padding to the distal tibia, sutures are necessary, and the skin is
neous cised to reduce the bulk of the poste- thus preventing later retraction of the closed with interrupted, widely
:i pos- rior flap (Figure 12). An unusually triceps surae from myostatic contrac- spaced, simple everting nylon sutures,
:d, di- bulky soleus may be tapered further to ture. Although muscle fascia can be placed witJ10ut the use of skin for-
.cl the reduce the thickness of the distal tibial simply sewn to periosteum, this tissue ceps. The intervals are reinforced with
tibial padding. If necessary, the medial is sometimes inadequate, in which adhesive paper strips (Figure 15 ).
its in- and/or lateral flap edges can be case direct myodesis to bone is rec- A well-padded plaster or fiberglass
.ved to t rimmed further to obtain a good fit. ommended. To best effect a secure cast is applied with the knee in 0° of
i (Fig- The cooled power saw is then used to myodesis to bone, a drill hole is extension. The drain tube is run be-
vessels cut a bevel in the anterior cortex of the placed on each side of the tibial crest tween the layers of cast padding and

flaps together over the end of the

bone (Figure 18).
Equal Medial and Lateral

(Sagittal) Flaps
T he advantages of equal medial and
lateral (sagittal) flaps were outlined
by Persson.34 The flaps are less apt to
become necrotic in dysvascular pa-
tients for two reasons. First, the con-
figuration and placement of the me-
dial and lateral flaps automatically
A
Figure 15 The skin is loosely cl osed with
widely spaced, everting, simple sutures reduce the amount of poorly vascu- Figu
alternated with adhesive paper strips. larized anterior skin that is left. Sec- the :
This technique requires no subcutaneous ond, the flaps are widely based and forrr
sutures or use of forceps on skin, mini- post
very short with reliable perfusion,
mizing damage to cutaneous circulation. sure
thus enhancing their viability (Figure tour
19). Persson also stated that a side-to- of ti
out the top of the cast so that it can side myoplasty covers the bone
be removed after 24 to 48 hours with- better and provides good spontane-
out disturbing the cast (Figu1·e 16). o us drainage. In trauma patients, an-
The cast is made as light as possible to other advantage is that the sagittal
allow the patient greater mobility in
bed and on crutches.
Figure 16 A lightweight immediate post-
operative cast is applied w it h t he knee in
o• of extension. Th e patella is heavily
flap design allows the skin to be more
easily cut proximal to any anterior or
posterior areas of missing or damaged
-
Equal Anterior and Posterior padded to prevent pressure ulcers. The skin, thus helping to preserve bony
Flaps drainage tube is led between the layers length (Figures 20 and 21).
of padding to exit proximally for easy re-
The absolute indication for equal an- moval without disturbing the cast.
terior and posterior flaps, which con- Skew Sagittal Flaps
serves bone length, is when relatively Robinson, 59 a vascular surgeon, de-
little bone remains. In this technique, and nerve are managed as described signed the technique using skew sagit-
A
the length of each flap is equal to half in the previous section. The tibia and tal flaps to enhance transtibial wound
the diameter of the leg at the level of fibula are cut as before. The long am- healing in severely dysvascular pa-
bone transection. Starting from a putation knife is used to create a pos- tients in whom alJ major vessels are FigL
occluded. Thermography, oximetry, t ior
rnidlateral apex on either side, the terior myofasciocutaneous flap. The
WOl
skin is cut to form equal anterior and vessels and nerves are dealt with as and vascular injection studies have in .f
posterior flaps (Figure 17). The ante- d escribed above. The anterior tibial shown that collateral circulation
rior investing fascia and the muscles cortex is beveled and contoured with through small arteries accompanying
of the anterior compartment are then a bone file. The wound is irrigated the saphenous and sural nerves sup-
cut down to the neurnvascular bun- and closed in a myoplastic manner by plies blood to flaps served by these Ion
dle. This bundle and the superficial suturing the investing fascia and myo- nerves.77 " 80 On the basis of these Slit
peroneal nerve and saphenous vein studies, an anteromedial flap incorpo- me

fascia of the posterior and anterior
rating tl1e saphenous nerve and artery fas,
and a posterolateral flap including the do
sural nerve and artery are recom- pa~
m ended in severely dysvascular pa- am
... ch,
I
,. tients. The fasciocutaneous flaps are
elevated from the muscles. If the pos-
terolateral flap is noted to have very
ag~
th.f
I
poor blood supply at the time of skin
incision, it can be shortened. The an- pa1
terior and lateral compartment mus- tio
Figure 17 Drawing showing skin incision for equal anterior and posterior flap design.
(Reproduced with permission from Epps CH: Amputation of the lower limb, in Evarts CM cles are divided at the same level as sid
(ed): Surge ry of the Musculoskeletal System, ed 2. New York, Churchill Livingstone, the bones, as are the deep posterior tia:
1990.) compartment muscles. ela

Le
td
~d
to
a-
n-
,e-
lly
u- figure 18 Application of equal anterior and posterior f laps to acute trauma in a 33-year-old man who sustained a gunshot injury to
~c- the superficial femoral artery. After three unsuccessful attempts to repair the injury, an open short transtibial amputation was per-
formed. A, lateral view just before closure 4.5 weeks after open amputation. Note the good granulation tissue formation and bulky
nd posterior f lap. B, Anterior view immediately after closure. Extensive trimming of posterior muscle tissue was required to achieve clo-
)11, sure. Equal anterior and posterior flap.s were used to preserve bony length. C, Anterior view 14 weeks after closure. Note the trim con-
ire tour achieved with the use of a shrinker sock and prosthesis. Full knee extension was achieved, but f lexion was limited to 90° because
to- of the bulk of the posterior t high muscles.
me
11e-
m-
ttal
ore
· or
ged
ony
- -( ,
de-
1git- A B c
und
pa-
are Figure 19 The technique for sagittal myofasciocutaneous f laps. A, Medial view showing t he flaps in re lation to the level of bone sec-
t ion in a short transtibial amputation. This method is easily adapted to any length transtibial amputation. B, Anterior view before
etry, wound closure. C, Anterior view showing midline closure. (Reproduced with permission from Epps CH: Amputation of the lower limb,
b.ave in Evarts CM (ed): Surgery of t he Mus<:uloskeletal System, ed 2. New York, Churchill Livingstone, 1990.)
.tion
ying
The gastrocnemius muscle is left thetic fitting. Using this technique, SK in orthopaedic patients with a variety
sup-
:hese long and fashioned into a flap that is Jain and associates82 reported satisfac- of diagnoses, excluding vascular dis-
sutured to periosteum over the tibial tory results in 28 dysvascular patients. ease, with satisfactory results in 48 of
'.hese
,rpo- medullary canal as a myodesis. The Rucl<ley and associates 83 reported 54 patients (89%).
rtery fasciocutaneous skew flaps are then on a randomized multicenter trial
closed, with the resulting suture ]ine comparing the skew flap and long pos- Medial Flap
g the
:om- passing obliquely between the tibia terior flap method of Burgess in 191 In an effort similar to Robinson and
pa- and the fibula, greatly reducing the patients with end-stage occlusive vas- Ward's work with skew flaps, AS Jain
s are chance of scarring to bone and dam- cular disease. No statistically signifi- and associates 84 attempted to capital-
pos- age from shear forces during pros- cant differences were found in early ize on the significant medial-to-lateral
very thetic gait81 (Figure 22) . healing and revision rates or walking skin blood -flow gradient often seen in
: skin In addition to enhancing healing in with a prosthesis. These investigators severely dysvascular patients by using
.e an- patients with only collateral circula- concluded that skew flaps offer an ad- a medially based flap. Using this tech-
mus- tion, this method is said to produce re- ditional acceptable method for trans- nique, they were able to salvage a trans-
v-d as sidual limbs that, because of their ini- tibial amputation in dysvascular pa- tibial level in 27 of 34 patients who
terior tial shape, require no shrinkage with tients. Robinson and Ward (personal would otherwise have required a
elastic socks or wraps before pros- communication, 2001) used skew flaps transfemoral amputation.

both world wars. Distal synostosis of

the tibia and fibula is claimed to pro-
d uce a residual limb with direct
weight-bearing capability, thus en-
hancing prosthetic gait and comfort.
Particularly in very short transtibial
residual limbs or in cases where se-
vere trauma has disrupted the in-
terosseous membrane, this technique
also prevents abduction of the fibula.
Ideally, the bones fuse distally in a
A
U shape. Direct weight bearing is said
to prevent bone atrophy as well.
Figu
The original technique is as fol-
Figure 20 Application of sagitt al myofasciocutaneous f laps to acute trauma in a 69- ShOI
lows: Two osteoperiosteaJ flaps are el- witf
year-old woman. A, Open traumatic transtibial amputation 8 days after initial surgery.
The tibia was fractured at the level of the wound apex. All soft tissue distal to the bone evated from the anteromedial and lat-
end was saved for secondary closure. B, Sagittal flaps were created by conservatively eral aspects of the tibia, beginning
trimming the edges of t he anterior defect and removing a narrow wedge of tissue pos- approximately 10 cm distal to the
teriorly opposite the anterior defect. The flaps were trimmed to fit, and the wound was proposed level of bone transection.
closed with minimal further loss of tibial length. Note t he suction drain.
The proximal attachments of these
flaps are carefully preserved. Once the
remainder of the amputation has
been completed, the lateral osteoperi-
osteal flap is sewn to the medial as-
pect of the fibula, and the anterome-
dial flap is sutured to its lateral
aspect. The flaps are then sewn to
each other to form a tube joining the
bone ends, which should then ossify
to form a sturdy weight-bearing bony
bridge (Figw-e 23) . Distal coverage in-
cludes myoplasty. This method has
been used in the US military, as re-
ported by Deffer,88 but to a much
lesser extent in the civilian popula-
tion. It has been recommended as a
useful technique, especially in young
traumatic amputees, both initially
and as revision surgery. 72 The chief
disadvantage of the original tech-
Fig1
nique is the sacrifice of significant sid1
bone length, particularly where there Ost,
Figure 21 A 26-year-old woman sustained trauma to the left leg, resulting in draining is sufficient mobile soft tissue present
painful nonunion of the tibia and fibula. A, Note the large anteromedial scarred and to adequately cover a greater length of
skin-grafted area. The patient requested transtibial amputation rather than further at- tibia. tib
tempts at salvage. Amputation using sagittal myofasciocutaneous f laps was performed. cor
B, Anterior view of the residual limb 8 weeks postoperatively. Th e large anteromedial
Dederich87 described an alterna-
skin defect was excised, and a narrow posterolateral wedge was removed, creating tive method of creating an osteoperi-
slightly skewed sagittal flaps, t hereby saving considerable tibial length. osteal tube requiring resection of only cec
1.5 to 2 cm of bone. Osteoperiosteal fro
flaps are raised medially and laterally fib
End-Weight-Bearing was first proposed by Bier in 1892. 85 from both the tibia and fibula, main· Ost
Transtibial Amputations This procedure was further developed taining their proximal attachments. leti
Distal Tibiofibular Synostosis by Ertl86 and later by Dederich87 for The exposed lengths of bone are ex· pla
Distal tibiofibular synostosis by revision of inadequate transtibial re- cised. The lateral tibial flap is sewn to i11t
means of an osteoperiosteal bridge sidual Umbs resulting from injuries in the medial fibu lar flap and the medial SU'!

s of
+jI 2cm Ii/
)fO·
I
rect
en-
'ort.
ibial
se-
m-
~ Gastrocnemius
ique
,ula.
muscle retained
/
m a A B
said
Figure 22 Skew flap technique. A, Anteromedial and posterol ateral skew flaps as seen laterally. B, Distal end of left residua l limb
fo]. showing the orientation of the skew flaps in relation to the tibia and fibu la as well as the axis of the sutured wound. (Reproduced
eel- with permission from Robinson KP: Skew flap myoplastic below-knee amputation: A preliminary report. Br J Surgery 1982;69:554-557.)
l lat-
ning
the
tion.
hese
~ the
has
peri-
l as-
lme-
.teral
n to
~ the
,ssify
bony
:e in-
has
.s re-
nuch
pula-
as a
oung
tiaHy Figure 24 Application of long posterior myofasciocutaneous flap to acute trauma in a
chief 60-year-old woman. A, Preclosure appearance of the transtibial amputation 10 days af-
ter the initial open procedure. All viable soft t issue distal to the bone ends was reta ined
tech- for secondary closure. B, The residua l limb 28 months after closure. Considerable bone
Figure 23 Radiograph of transtibia l re-
kant sidual limb 5 months after Ertl osseoperi- length was saved by use of t he long posterior myofasciocutaneous flap retained at ini-
there osteal t ibiofibular synostosis. tial debridement. Scar placement caused no prosthetic problems.
·esent
;th of
tibial flap to the lateral fibular flap, has been a recent resurgence of inter- various techniques use the plantar
erna- completing the tube. 86 est in bone bridging, largely stimu- soft tissues with or without a portion
Further modifications of the pro- lated by amputees themselves. It is of the calcaneus in the form of an is-
1peri-
Fonly cedure include creation of a bridge hoped that ongoing studies of this land pedicle flap based on the poste-
osteal from a salvaged distal portion of the technique will provide some objective rior tibial vessels and tibial nerve. The
erally fibula. The bone is cut, but the peri- data to support the claims of its pro- indications are limited but include
nain- osteum and attached musculature are ponents. unreconstructable tibial bone loss,
1ents. left intact. The fibular fragment is Foot Fillet Procedures Foot fillet massive circumferential skin loss be-
:e ex- placed between the bone ends, set procedures represent another ap- tween the knee and ankle from de-
wn to into a slot in the tibia, and secured by proach to end weight bearing in trans- gloving or deep burns, and infected
1ediaJ sutures, a wire, or .a screw.85•89 There tibial amputations for trauma. The tibial nonunion with extensive skin

carefully preserving the fibrous at- technique preserves the maximum

son,
tachment of the heel pad to the calca- amount of limb length (Figure 24).
Instf
neus. The calcaneus is then divided In cases of irreparable loss of foot
dost
between the posterior and middle fac- vascularity and sensation associated
hool
ets. The intact neurovascular bundle with segmental tibial fracture, frag- mus·
is folded into the soft tissues with care ments of tibial shaft may remain well out 1
to avoid kinking. T he flap is then ro- attached to soft tissue. These bony ture:
tated so that the durable sole skin will fragments can be fixed to the proximal
pap€
fill any major skin defect. The calca- part of the shaft by internal or external
fat.
neal fragment is shaped and wired to fixation to provide a longer residual ture:
the end of the tibia. The resul tant re- limb (Figures 25 and 26). al!o,
sidual limb is quite bulbous initially In some trauma patients there is com
but assumes a suitable contour over enough muscle to adequately cover ratie
time with wrapping and/or shrinker the bones but insufficient skin to fasci
socks and prosthetic weight bearing. completely dose the wound. It is not may
necessary in these cases to shorten the to ti
Open Amputations bones to the level where full coverage not
Open an1putation is indicated when- by skin is possible. Available skin can dun
ever primary closure of the wound is be rotated to cover the anterodistal will
likely to result in initial or continuing part of the tibia, the site where the
infection and/or necrosis. This applies greatest stress occurs during pros-
equally to traumatic amputations and thetic walking. The remainder of the Tre
to cases of infection in which an at- muscle is covered with a split- The
tempt will be made to preserve maxi- thickness skin graft (Figures 27 be c
mum limb length below the knee to and 28) .
Figure 25 A 36-year-old man sustained and
segmental t ibial fractures and a crushed
enhance prosthetic function . The In severe foot infection, an open nevi
foot. He underwent a transtibial amputa- "guillotin e" amputation, in which all ankle disarticulation is useful if the rOUJ
t ion of the right limb. A, Lateral and AP soft tissue and bone are transected at distal tibia is not involved. Otherwise, age
rad iographs of the resi dual limb. The the same level, is rarely indicated and a supramalleolar amputation is re-
wound was left open. B, Lateral photo· sen
even then should be done only at dis- quired to remove infected bone. 91 If cioe
graph of t he mature residual limb dem-
onst rates that significant length was tal levels to leave enough proximal the leg compartments are involved, takf
saved by the use of internal fixation tissue to create flaps for a functional they may be easily opened medially is i
rather than by amputating through one transtibial amputation at the time of and/or laterally for thorough debride- botl
of the fracture sites. revision. The open circumferential ment. Partial or complete closure is stre
technique, in which each successive usually possible in 10 to 14 days65 ove:
layer is cut and allowed to retract be- (Figure 29). the
loss. 90 The foot should be basically fore cutting deeper layers, has the ad-
ma~
sound with protective plantar sensa- vantage of minimizing exposure of
tion and perfusion from the posterior the deeper soft tissues and bone and
Special clo~
pre·
tibial artery. As described by Singer, 22 perhaps conserving some bone Considerations bor.
the heel pad and remainder of the length. The technique does, however, During Transtibial fore
sole are dissected from the pedal skel- require revision to allow good soft-
eton, carefully preserving the neu- tissue coverage over the end of the
Amputation terf
rovascular bundle. The nerve is sepa- bones. A much better technique uses Treatment of Skin
rated from the vessels and folded into open flaps. In this case, all viable tis- To have a successful amputation, the Tr,e
the soft tissues of the residual limb. sue is preserved by forming rough one tissue structure that m ust heal is Mu
A posterior tibial-popliteal arterial myofasciocutaneous flaps, the length the skin. The skin-subcutaneous inci- son
anastomosis is done, and the heel pad and orientation of which are dictated sion should be made at 90° to the sur- the
is sutured over the end of the tibia to by the trauma or infection. Alth ough face to avoid having portions of skin gen
provide direct weight bearing. Patter- such flaps may appear excessively long unsupported by subcutaneous tissue not
son aJ1d associates90 described an- initially, considerable shrinkage oc- and, hence, making it more difficult inv
other method of achieving end bear- curs by the time closure is feasible. If to accurately appose these layers, trir
ing using an osteocutaneous flap the flaps are so long that some distal making them more prone to necrosis. for
derived from the sole and calcaneus. viability is lost, this portion may be At no time should the skin be trau- nee
The sole is dissected proximal ly from removed at the time of closure. Of matized by grasping with for- nee
the forefoot and midfoot skeleton, ceps. 13'15' 19'33'45·50 For the same rea-
these three techniques, the open flap mu
Ch apter 38: Transtibial Amputation: Surgical Managem ent 495
um son, the use of staples is discouraged.

I. Instead, skin edges can be everted for
oot closure by the suturing needle, skin
tted hooks, or gloved fingers. The skin
:ag- must be precisely approximated with-
well out tension. Simple, widely spaced su-
ony tures can be alternated with adhesive
mal paper strips to contain subcutaneous
rnal fat. In dysvascular patients, the su-
iual tures are kept in place for 3 weeks to
allow for the slower healing that is
·e is common.20 There sbould be no sepa-
over ration of layers in the creation of myo-
t to fasciocutaneous flaps because this
not may interfere with the blood supply
t the to the skin. The residual limb should
rage not be left witl1 inverted scars or re-
can dundant skin, or with "dog ears" that
listal will not atrophy promptly.
, the
>ros-
f the Treatment of Fascia
;plit- The crural or investing fascia should
27 be cut at tl1e same level as the skin
and subcutaneous tissue. It should
open never be separated from the sur-
f the rounding soft tissues to prevent dlarn-
wise, age to any small perforating vessels
s reserving the skin. In closing a myofas-
_91 If
ciocutaneous flap, care should be
>lved, taken to ensure that the crural fascia
dially is indeed found and firmly sutured
1ride- boili to ensure maximal wound
1re is strength and to take tension off the
lays65 overlying skin. This, in turn, allows
the use of fewer skin sutures, which Figure 26 A 22-year-old man sustained bilateral lower limb injuries in an auto racing ac-
may lessen skin necrosis. Complete ci dent. A, Lateral radiograph of t he ri ght leg shows the open com minuted t ibial and f ib-
closure of the investing fascia also ular fract ures with external fixator in place. B, Medial view of the right open ankle dis-
articulation. Th e most distal pin has been removed and t he frame shifted proximally to
prevents scarring of skin directly to
allow sufficient room for post erior f lap development at the long transtibial level. C, Me·
bone, allowing dissipation of s.hear dial view showing dist al cl osure and healing of the midcalf wound by contraction.
forces generated at ilie skin-socket in- D, Medial view 10 months after closure. The contracted scar of the calf wound was ex-
terface. cised and cl osed directly. Note t he excellent length and shape of the limb. E, Left lower
limb w it h painf ul ankle/foot arthrosis and deformity. Two years later, the patient re-
quested a second t ranstibial amputati on rather than further attempt s at reconstruction.
n, the Treatment of Muscle F, Four years after t he inj ury, the resi dual limbs are well matured. G, Pat ient training for
a triathlon 4 years after the injury.
1eal is Muscle is considered to carry at least
s inci- some blood from ilie deep arteries of
te sur- the leg to the skin. It is, therefore,
,f skin generally accepted that muscle should coagulator, should be excised. T his Treatment of Nerves
tissue not be dissected from its overlying condition appears most commonly in
ifficult Five nerves should be found and
investing fascia. Muscle may be the anterior compartment. If muscle
layers, transected during transtibial amputa-
trin1med, leaving sufficient padding tissue is merely pale, it may be left be-
crosis. cause it will probably fibrose in time. tion: ilie superficial peroneal, saphen-
for the end of ilie tibia without un-
: trau- Healing can occur following the com- ous, deep peroneal, smal, and tibial
necessary bulk. Any ischemic or
for- plete removal of necrot ic muscles so nerves. The tibial nerve may present
necrotic muscle, as determined by
Le rea- minimal stimulation with ilie electro- long as the skin remains viable. sufficient intrinsic vascular supply to

protected during prosthetic gait. Del- rigate

lon and associates92 demonstrated detrit
that nerve ends surgically buried in To
muscle show no tendency to form requi:
neuromas. elitis
cumf.
Treatment of Bone form,
Beveling of the tibia combined with eficia
careful smoothing of the bone edges putat
will prevent damage to the skin in its dew
position between the hard bone sur- head
face and the firm prosthetic socket. prese
Various authors have suggested a bevel of th
of 45° to 60° to be optimal. 11 •16•21 •93 Ali over
bone cutting with a power saw should tibia ·
be done with saline cooling to prevent the h
thermal necrosis. 72 If the surgeon sever
nervt
wishes to avoid fluid splattering, a
WOUJ
Gigli saw may be used instead to cu t
Figure 27 A 21-year-old man was injured in a farming accident. A, Open transtibial am- form
the tibial shaft from posterior to ante-
putation. At initial debridement, t he exposed t ibia was retai ned as an internal splint to press
rior. As the saw enters the anterior cor-
prevent contraction of posterior soft t issues. The wound is well covered with granula- fibul
tion tissue and ready for revision and closure. B, The residual limb 3 months after clo- tex, it is directed proximally to cut the
tery
sure. Exposed bone was excised and t he anterodistal tibia was covered with a sensate bevel.
wax:
narrow posterior flap. The remaining medial and lateral defects were covered with split- The fibula should be no more than
t hickness skin grafts. The patient was fitted with a prosthesis and returned to farm work ten de
0.5 to I cm shorter than the tibia if a
without incident. (Reproduced from Bowker JH: Surgical techniques for conserving tis- react
sue and function in lower-limb amputation for trauma, infection and vascular disease. conical shape of the distal residual heili
Instr Course Leet 1990;39:355-360.) limb with a prominent distal end of
the tibia is to be avoided.71 To prevent
soft-tissue impingement during pros- Im
warrant ligation or cauterization of The b est approach appears to be sim-
its vasa nervorum. A variety of meth- ple sharp division following mild
thesis use, the fibula may be cut with a Po:
bevel facing. posterolateralJy. Both
ods have been advocated to inhibit traction on the nerve. 7 L The cut prox- Mc
bones should be carefully filed to re-
neuroma formation by traumatizing imal end retracts into the soft tissues A Jig
move all sharp edges and points. Be-
the proximal cut end of the nerve. where the inevitable neuroma will be end
fore closure, the wound should be ir-
B
Figu
Figure 28 A 40-year-old woman sustained trauma to the left leg. A, Open left traumatic transtibial amputation ready for closure. Note resic
the reta ined posterolateral soft tissue. At the time of initial debridement, this flap was considerably larger, but it contracted over the stab
intervening 10 days. B, Residual limb 1 month after the tibia was covered by rotation of a local myofasciocutaneous flap. Coverage that
elsewhere is by muscle tissue only, w hich is ready for split-thickness skin grafting onto t he granulation tissue base. c, Five weeks later, arnp
the graft is mature enough for application of a shrinker sock. of P,

Chapter 38: Transtibial Ampu tation: Surgical Management 497
'el- rigated generously to wash away bone

ted detritus.
in Total removal of the fibula may be
rm required in cases of fibular osteomy-
elitis or bony necrosis caused by cir-
cumferential muscle loss or abscess
formation . Removal may also be ben-
rith eficial in a very short transtibial am-
lges putation at the level of the tibial tuber-
cle where, if left in place, the fibular
I its
head may produce pain by its ball-llike
mr-
presence in the socket. After excision
ket.
of the fibula, an intimate socket fit
eve!
I All
over the entire circumference of the
tibia can be achieved (Figure 30) . With
mld
the hip extended and the knee flexed,
fent
several centimeters of the peroneal
;eon
nerve can be drawn gently into the Figure 29 A 43-year-old man w it h type 1 diabetes mellitus required transtibial amputa-
g, a wound, after which the neuroma will tion. A, Severely abscessed foot and ankle before supramalleolar amputation and thor-
cut
form in the thigh, away from socket ough debridement through extensile incisions of all crural compartments for ascending
nte- purulent infection. B, At t ime of definitive transtibial amputation 17 days later, all com-
pressure. Bleeding from the tibia or
cor- fibula can be con trolled by electrocau- partments and the distal portion of the wound had abundant granulation tissue. The
t the wound edges and granulation tissue were excised in all areas t hat could be closed. C, Lat-
tery and closure of the wound. Bone eral view showing distal closure with myodesis of the soleus and partial closure of the
wax should not be used because of its anterior compartment wound. At the same time, partial proximal closure of the posterior
than tendency to provoke a foreign-body compartment wound was done. D, Three months after initial open amputation, both re-
I if a reaction and its interference with firm maining wounds had healed by secondary intention, and the limb was ready for pros-
dual thetic fitting.
healing of muscle to bone .
.d of
:vent tient is generally comfortable and, if
Immediate with the knee in full extension has
nos- several advantages. This prevents knee the rigid dressing is light enough, can
rith a Postoperative flexion contracture dming the first move about in bed quite easily. An-
Both M anagement other advantage of the rigid dressing
few painful postoperative days, pro-
ore- is that it protects against falls onto the
A lightweight rigid dressing from the tects the wound from bed trauma,
.. Be-
end of the residual limb to midthigh and limits edema formation. The pa- residual limb while the patient learns
)e ir-
Figure 30 Very short transtibial amputation. A, Anterior radiograph of a very short traumatic t ranstibial amputation with a prominent
~. Note resid ual f ibula. B, lntraoperative view of the same limb shown in A demonstrating excision of the residua l fibula to allow intimate,
ver the stable circumferential fit of t he socket to the tibia. Th e peroneal nerve (in clamp) was shortened under moderate tension to ensure
,verage that the neuroma would form above the knee, well proximal to the socket brim. C, AP radiograph of another very short transtibial
:slater, amputation fol lowing removal of the fibula, showing a smooth lateral tibial contour, allowing an intimate socket f it. (A and B courtesy
of Prof. Georg Neff, Berlin, Germany.)

knee regularly. One randomized study oral narcotics or nonsteroidal anti- decon
comparing soft and rigid dressings inflammatory drugs. In this way, ha- just a
showed that rigid dressings resulted bituation should not occur. Avoidance ative <
in less pain, an improved sense of of wound dependency should also in a c
well-being, and earlier prosthetic fit- help prevent pain. vated
ting. 10 In another series, hospital stay A different approach to modula- then<
was reduced from 14 to 7 days. 46 A tion of both immediate postoperative the p
posterior plaster splint will keep the and phantom limb pain arose from ginnil
knee straight as long as the splint is observation of the similarities be- This i
not broken and the wrapping is firm. tween preoperative limb pain and crutcl
If it is necessary to look at the wound, postoperative phantom pain. In 11 pa- and b
however, a better plan is to make a tients, Bach and associates 95 found In
strong posterior hemicylinder by re- that a lumbar epidural blockade with IPOP
moving the anterior half of a full cast. bupivacaine and morphine, given comp
An alternative method, used in a 72 hours preoperatively, greatly re- cast,
limited number of centers because it duced the incidence of phantom limb tion- 1
requires excellent patient compliance, pain at 7 days, 6 months, and 1 year af- plied,
is the immediate postoperative pros- ter surgery compared with a similar resid1
thesis (IPOP). The protocol devel- control group of 14 patients. A second diatel
oped by Smith and Fergason 94 can be group of investigators then conducted stratE
summarized as follows. For diabetic/ a randomized, double-blind trial in 60 prop1
dysvascular patients and trawna pa- patients in whom the blockade or a sa- curat
Figure 31 Shrinker sock applied to a re- tients with amputation above the 1ine placebo was begun 18 hours be- Tl
sidual limb after transtibial amputation zone of injury, the usual rigid dress- fore surgery. The trial showed no sig- comE
was tightened twice within the I
ing is applied on the operating table. nificant difference in the incidence of
4 weeks as the residual limb volume de-
creased. Lack of fu rther atrophy in the If wo1md healing is seen to be pro- phantom limb pain between the two the I
previous week indicated readiness for gressing normally at 5 to 7 days post- groups at 1 week or at 3, 6, or folio'
prosthetic fitting. operatively, a pylon and foot are at- 12 months postoperatively.96 heale
tached to the second cast. Weight Alternatively, a small Silastic cathe- thesi
bearing starts at 20 to 30 lb. Following ter may be inserted at the time of sur- use.
to manage a walker or crutches. If long,
each weekly cast change, weight bear- gery within or next to the tibial nerve
necessary, the rigid dressing can be amp:
ing is increased by 30 lb. When resid- sheath for administration of local an-
secured with a waist belt. The only the l
ual limb volume is no longer decreas- esthetic for the first 72 hours postop-
disadvantage is that the wound can- ing and the skin is wrinkled, a unle:
eratively, as advocated by Malawer
not be readily inspected. Careful at- shrinker sock is applied and pros- and associates. 97 In another study of maxi
tention to the patient's general status, thetic fitting begun. If amputation for this technique, Elizaga and associ- tram
however, such as an otherwise unex- trauma has been done through the ates98 found no effect on postopera- In tl
plained fever or evidence of excessive zone of injw·y, a more cautious ap- tive opioid requirements or phantom goal:
drainage, will inform the surgeon of proach is required to protect marginal limb pain. <lorn
any indication for removal of the cast. tissue, split-thickness ski n grafts, or Preventing infection is an impor- inch
The cast is worn for 3 weeks with open areas. Application of the !POP is tant goal of postoperative manage- folio
weekly changes for wound inspection delayed until the wound is completely ment that is usually met with periop- patii
and full range of motion of the knee. healed, at which point it may be con- erative intravenous antibiotics. lf theti
A shrinker sock is then worn continu- sidered unnecessary if residual limb infection is an overriding factor in the case:
ously, except for bathing, until r.esid- edema has resolved during the in- amputation, however, one or more vane
ual limb volume has stabilized. The terim. In this case, shrinker sock ap- antibiotics chosen from organism low~
sock is tightened or changed as vol- plication and prosthesis fitting can be sensitivity tests should be continued tanc
ume decreases (Figure 31). done without further delay. c
1or 2 to 5 d ays postoperative . ly. 20.29 1
A soft dressing, on the other hand, The issue that most concerns pa- Further need for antibiotics can be put~
allows easy access to the wound for tients during the immediate postop- determined by direct evaluation of vari,
inspection and for motion of the knee erative period is pain control. Patients the wound. Atelectasis can be pre- the
with or without the guidance of a should be given an amount of narcot- vented by positioning and by deep thet
therapist. It does not, however, pro- ics sufficient fo r good pain relief breathing exercises using various tee
tect the wound from trauma, nor every 3 to 6 hours or by means of an types of incentive respiratory devices. pati
does it prevent knee flexion contrac- on-demand machine for a max- The patient should be made mo- can
ture if the patient does not move the imum of 5 days, then switched to bile as soon as possible to prevent the con:

Chapter 38: 1ranstibial Amputation: Surgical Management 499
1ti- deconditioning that may occur within also be extremely helpful in facilitating References
ha- just a few days. On the first postoper- the amputee's transition to the com- 1. Boontje AH: Major amputations of
nee ative day, the patient should be sitting munity, especially by providing a com- the lower extremity for vascular dis-
Llso in a chair with the residual limb ele- fortable social, educational, and recre- ease. Prosthet Orthot Int 1980;4:87-89.
vated to the level of the chair seat. By ational outlet. 2. Fearon J, Campbell DR, Hoar CS, et al:
1la- the next day, the patient should be in Improved results with diabetic below-
tive the physical therapy department 'be- knee amputees. Arch Surg 1985; 120:
om ginning ambulation on parallel bars. Summary 777-780.
be- This should be foUowed by the use of Transtibial amputation, by saving the 3. Harris JP, Page S, Englund R, et al: Is
and crutches or a walker as conditioning knee joint, provides the amputee with the outlook for the vascular amputee
pa- and balance improve. the possibility of near-normal ambu- improved by striving to preserve the
und In recent years, introduction of the lation and overall lifestyle. With the knee? J Cardiovasc Surg 1988;29:
vith IPOP and its most commonly used availability of new information on the 741-745.
iven component, the rigid postoperative efficacy of transtibial amputation and 4. Kacy SS, Wolma FJ, Flye MW: Factors
re- cast, has enhanced early mobiliza- improved methods of determining po- affecting the results of below-knee
imb tion. 17'30'63 If an !POP has been ap- tential healing levels in a limb, most amputation in patients with and witl1-
r af- plied, limited weight bearing on the out diabetes. Surg Gynecol Obstet 1982;
major lower limb amputations are
residual limb can start almost imme- l 55:513-518.
1ilar now being done at the transtibial
ond diately, provided the patient demon- 5. Keagy BA, Schwartz Ja, Kotb M, et al:
rather than the transfemoral level. Di-
strates sufficient strength, balance, Lower extremity amputation: The
cted abetes mellitus is now the primary or
proprioception, and cognition to ac- control series. J Vase Surg 1986;4:
n 60 secondary cause of amputation in at
curately determine the weight applied. 321-326.
a sa- least 50% of patients in developed
The cost of a hospital stay has be- 6. Rizzo RL, Matsumoto R: Above versus
, be- countries. Most patients with dysvas-
come a major issue in recent years. In below knee amputations: A retrospec-
sig- cular limbs have one or more signifi-
the past, many patients remained in tive analysis. Int Surg 1980;65:265-267.
:e of cant associated diseases calling for de-
the hospital or rehabilitation center 7. Bard G, Ralston JH: Measurement of
two tailed preoperative management and
following surgery until they h ad energy expenditure during ambula-
·, or skilled care in the immediate postop- tion, with special reference to evalua-
healed and had been fitted with a pros-
erative period. tion of assistive devices. Arch Phys Med
ithe- thesis and thoroughly trained in its
The aim of amputation surgery is a Rehabil 1959;40:415-420.
sur- use. In the United States, this is no
well-healed, sensate, fru1ctional end 8. Gonzalez EG, Corcoran PJ, Reyes RL:
1erve longer financially feasible. Transtibial
organ that will interface well with a Energy expenditure in below-knee
l an- amputees are often discharged from
prosthesis. Selection of lengtl1 is based amputees: Correlation with stump
stop- the hospital 4 to 5 days after surgery length. Arch Phys Med Rehabil 1974;55:
on etiologic factors and on clinical
lawer unless they have failed to ach ieve their 111 - 119.
maximum level of independence in and laboratory evaluation. As much
:iy of length as possible should be pre- 9. Wagner FW Jr: Resident Training Man-
iSOci- transfers and one-legged ambulation. ual. Downey, CA, Rancho Los Amigos
served, compatible with eradicating
pera- In that case, they will stay until these Medical Center.
goals have been achieved or aban- disease and with good prosthetic
ntom 10. Barber GG, McPhail NV, Scobie TK, et
doned as unrealistic. All further care, function. Meticulous management of
tissues will lead to preservation of the al: A prospective study of lower limb
11por- including prosthetic fitting a nd amputations. Can J Surg 1983;26:
follow-up, is accomplished on an out- length obtained at surgery. Myodesis
nage- 339-341.
patient basis. Hospitalization for pros- is advocated because it provides the
:riop- ll. Bickel WH: Amputations below the
thetic gait training can be justified in most stable soft-tissue envelope. Post-
:s. If knee in occlusive arterial diseases.
cases of marked deconditioning, ad- operative rigid dressings are strongly Surg Clin North Am 1943;23:982-994.
in the
vanced age, bilateral concomit ant recommended because of local pro-
more 12. Block MA, Whitehouse FW: Below-
lower limb amputations, or great dis- tection of the wound and the preven-
rnism knee amputation in patients with dfa-
tance from the center. tion of edema and knee flexion con- betes mellitus. Arch Surg 1963;87:
inued
iy.20,29 The psychological needs of the am- tracture. Early mobilization prevents 682-689.
an be putee must also be met. Counseling by deconditioning, thereby all.owing the 13. Chilvers AS, Briggs J, Browse NL, et al:
on of various team members can help allay early discharge to outpatient status. Below- and through-knee amputa-
~ pre- the patient's anxiety about the pros- Early prosthetic weight bearing has tions in ischaemic disease. Br J Surg
deep thetic phase of care. A trained ampu - great value in selected patients if they 1971;58:824-826.
arious tee peer counselor matched with the are closely monitored. Optimal am- 14. Cumming JGR, Jain AS, Walker WF, et
~vices. patient's age, sex, and amputation level putee management is best achieved al: Fate of the vascular patient after
e mo- can be of inestimable help. Amputee/ through a team approach, beginning below-knee amputation. Lancet 1987;
:nt the consruner peer support groups can even before surgery. 2:613-615.

15. Hoar CS, Torres J: Evaluation of RA, et al: Below-knee amputation: Is in diabetes. Inf Dis N Amer 2001;15: 58. S
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treatment of diabetic gangrene. N Engl justified? Arch Surg 1980; 115: 44. Dwars BJ, Rauwerda JA, van den Brock jJ
J Med 1962;266:440-443. 1184-1187. TAA, et al: A modified scintigrafic 1
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Below-knee amputation for ischemic The fate of the below-knee amputee. tion in diabetics. Eur J NuclMed 1989; l:
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I 25:493-501. 31. Ecker JL, Jacobs BS: Lower extremity 45. Alter AH, Moshein J, Elconin KB, et al:
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the knee amp utation for ischemic gan- Diabetes 1970;19:189-195. ittal technique: A comparison with the
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operative fi tting technique. Am J Surg putees. SurgGynecol Obstet 1980;151: 46. Baker WH, Barnes RW, Shurr DG: The
1972;124:127-134. 41-44. healing of below-knee amputations: A
18. Murray DG: Below-knee amputations 33. Kendrick RR: Below-knee amputation comparison of soft and plaster dress- 61. 1
in the aged: Evaluation and prognosis. in arteriosclerotic gangrene. Br J Surg ings. Am J Surg 1977;133:716-7 18.
Geriatrics 1965;20:2033-1038. 1956;44:13-27. 47. Harris PD, Schwartz SI, DeWeese JA:
19. Perry T: Below-knee amputations. 34. Persson BM: Sagittal incision for Midcalf amputation for peripheral
Arch Surg 1963;86:199-202. below-knee amputation in ischaemic vascular disease. Arch Surg 1961;82:
20. Robinson K: Long-posterior-flap myo- gangrene. J Bone Joint Surg Br 1974;56: 381-383. 62.
plastic below-knee amputa tion in is- 110-114. 48. Murdoch G: Amputation su rgery in
chaemic d isease: Review of experience the lowe r extremity. Prosthet Orthot Int
35. Yaramenko D, Andruhova RV: Below-
in 1967-1971. Lancet 1972;2:193-195. 1977;1 :72-83.
knee amputation in patients with vas-
21. Roon AJ, Moore WS, Goldstone J: Be- 49. Pohjolainen T, Alaranta H : Lower limb 63.
cular disease and prosthetic fitting
low-knee amputation: A modern ap- problems. Prosthet Orthot Int 1986;10: amputations in southern Finland.
proach. Am J Surg 1977;134:153-158. 125-128. Prosthet Orthot Int 1988;12:9-18.
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et al: The fillet foot for endweigh t- tion for ischaemic gangrene. Acta
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37. Cranley JJ, Krause RJ, Strasser RS, et 64.
23. Paloscbi GB, Lynn RB: Major amputa- Johansen KH: Open tibial fractures
al: Below-the-knee amputation for with associated vascular injuries:
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lar disease with particular reference to Prognosis for limb salvage. J Trauma
l 969;98:77-80. 1985;25:203-208.
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Can J Surg 1967;10:168-171. 38. Thornhill HL, Jones GD, Brodzka W, 52. Pedersen HE, LaMont RL, Ramsey
65.
et al: Bilateral below-knee amputa- RH: Below-knee amputation for gan-
24. Smith BC: A twenty year follow-up in tions: Experience with 80 patients. grene. South Med J 1964;57:820-825.
fifty below-knee ampu tations for gan- Arch Phys Med Rehabil 1986;67: 53. Lipsky BA: Evidence-based antibiotic
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39. McCo Uough NC, Jennings JJ, Sar- FEMS lmmunol Med Microbial 1999;26: 66.
25. Fletcher DD, Andrews KL, Hallett JW 267-276.
miento A: Bilateral below-the-knee
Jr, et al: Trends in rehabilitation after 54. Lipsky BA, Berendt AR: Principles and
amputation in patients over fifty years
amp utation for geriatric patients with practice of antibiotic therapy of dia-
of age: Result in 31 patients. J Bone
vascular disease: Implications for fu- betic foot infections. Diabet Metab Res
Joint Surg Am 1972;54:1217-1223.
ture health resource allocation. Arch Rev 2000;16(suppl l ):S42-S46.
Phys Med Rehabil 2002;83:1389-1393. 40. HeUer RF, Hayward D, Hobbs MST: 67.
55. Dickhaut SC, Delee JC, Page CP: Nu-
26. Purry NA, Hannon MA: How success- Decline in rate of death from is-
tritional status: Importance in predict-
ful is below-knee amputation for in- chaemic heart disease in The United
Kingdom. BMJ 1983;286:260-262. ing wound-healing after amputation.
jury? Injury 1989;20:32-36. J Bone Joint Am 1984;66:71-75.
27. Dougherty PJ: Transtibia1 ampu tees 41. Stewart CPU: The influence of smok- 68.
56. Pinzur MS, Smith D, Osterman H:
from the Vietnam War: Twenty-eight ing on the level of lower limb amputa- Syme ankle disarticulation in periph-
year follow-up. J Bone Joint Surg Am tion. Prosthet Orthot Int 1987;11: eral vascular disease and diabetic in-
200 I ;83:383-389. 113-116. fection: The one-stage ve rsus tv,o-
28. Sarmiento A, \"larren WD: A re- 42. Rush DS, H uston CC, Bivins BA, et al: stage procedure. Foot Ankle Int 1993; 69
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tions. Surg Gynecol Obstet 1969; 129: above knee and below knee amputa- 57. Sieggreen MY: Healing of physical
799-802. tions. Am Surg 1981;47:36-39. wounds. N11rs Clin North Am 1987;22:
29. Castronuovo JJ, Deane LJ, Deterling 43. Calvet HM, Yoshikawa TT: Infection 439-447. 70

58. Stotts NA, Washington DF: Nutrition. Br J Hosp Med 1970;4:596-604. 87. Dederich R: Die muskelplastischen
A critical component of wound heal- 71. Burgess EM: The below-knee amputa- Amputationssttimpfe. Orthop Techn
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>ck
1990;1:585-594. 72. Marsden FW: Amputation surgical 88. Deffer PA: More on the Ertl osteo-
59. Robi nson K: Skew flap myoplastic technique and postoperative manage- plasty. Amputee Clin 1970;2:7-8.
19; below-knee amputation: A prelimi- ment. Aust N ZJ Surg 1977;47: 89. Pinto MAGS, Filho NA, Guedes JPB,
nary report. Br J Surg l 982;69:554- 384-392. Yamahoka MSO: Bone bridging in
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' al:
60. Bowker JH: Questions to ask your am- Surg l 944;26:626-634. 1998;33:525-531.
ag-
the putation tean1 members before sur- 74. Epps CH Jr: Amputation of the lower 90. Patterson BM, Smith AA, Holdren
78;
1 gery, in First Step: A Guide for Adapting limb, in Evarts CM (ed): Surgery of the AM, Sontich JK: Osteocutaneous pedi-
to Limb Loss, ed 2. Knoxvi lle, TN, Am· Musculoskeletal System, ed 2. New York, cle flap of the foot for salvage of
putee Coalition of America, 2001, below-knee amputation level after
fhe NY, Churchill Livingstone, 1990.
pp 10-11. lower extremity injury. J Trauma 2000;
:A 75. McCollough NC III, Harris AR,
61. Lind J, Kramhoff M, Bodtker S: The 48:767-772.
S· Hampton FL: Below-knee amputation,
influence of smoking on complica- 91. Mcintyre KE Jr, Bailey Sa, Malone JM,
in Atlas of Limb Prosthetics. St. Louis,
tions after primary amputations of the et al: Guillotine amputation in the
\: MO, Mosby-Year Book, 1981,
lower ext remity. Clin Orthop 1991;267: treatment of nonsalvageable lower-
pp 341-368.
211-2 17. extremity infections. Arch Surg 1984;
76. Loon HE: Below-knee amputation
62. Ebskov LB, Schroeder TV, Holstein PE: 119:450-453.
surgery. ArtifLimbs 1961;6:86-99.
Epidemiology of leg amputation: The 92. Dellon AL, MacKinnon SE, Pestronk
77. McCollum PT, Spence VA, Walker WF,
influence of vascular surgery. Br J Surg A: Implantation of sensory nerve into
t Int Murdoch GA: A rationale for skew
1994;81 : 1600- 1603. muscle: Preliminary clinical and ex-
flaps in below-knee amputation sur-
63. Van Niekerk LJA, Stewart CPU, Jain perimental observations on neuroma
imb gery. Prosthet Orthot Int 1985;9:95-99.
AS: Major lower limb amputation fol- formation. Ann Plast Surg 1984;
78. Towne JD, Condon RE: Lower extrem- 12:30-40.
lowing failed i11frainguinal vascular
ity amputations for ischaemic disease.
bypass surgery: A prospective study on 93. Harris WR: Below-knee amputation: A
ta· Adv Surgery 1979;13:199-227.
amputation levels and stump compli- technical note. Can JSurg 1987;30:
79. Gray DWR, Ng RLH: Anatomical as-
cations. Prosthet Orthot Int 2001;25: 392-393.
pects of the blood supply to the skin
29-33.
of the posterior calf: Technique of be- 94. Smith DG, Fergason JR: Trans tibial
64. Ebskov LB: Hindsok, Holstein P: Level
low knee amputation. Br J Surg 1990; amputations. Clin Orthop Rel Res 1999;
of amputation following failed arterial
77:662-664. 361:108-115.
reconstruction compared to prima ry
amputation: A meta-analysis. Eur J 80. Haertsch P: The surgical pla.ne in the 95. Bach S, Noreng MF, Tjellden NV:
Vase Endovasc Surg 1999;17:35-40. leg. Br J Plast Surg 1981;43:464-469. Phantom limb pain in amputees dur-
81. Robinson KP: Skew-flap below-knee ing the first 12 months following limb
65. Bowker JH: Surgical techniques for
an· amputation. Ann R Coll Surg Engl amputation, afte r preoperative lumbar
conserving tissue and fu11ction in
:5. l 991;73:155-157. epidural blockade. Pain 1998;33:
lower-limb amputation for trauma,
,tic 82. Jain SK, Sanyal NC, Poonekar PD: An 297-301.
infection, and vascular disease. Instr
Course Leet 1990;39:355-360. improved technique for below-knee 96. Nikolajsen L, llkjaer S, Christensen
1 9;26: 66. Cheng EY: Lower extremity amputa- amputation in ischemic limbs. Med J JH, Kronerk K, Jensen TS: Ran-
tion level: Selection using noninvasive Armed Forces India 1988;44:191-195. domised trial of epidural bupivacaine
;and hemodynamic methods of evaluation. 83. Ruckley CV, Stonebridge PA, Prescott and morphine in prevention of stump
ia- Arch Phy Med Rehabil 1982;63: RJ: Skew flap versus Jong posterior and phantom pain in lower limb am-
1Res 475-479. flap in below-knee amputations: Mul- putation. Lancet 1997;350: 1353-1357.
ticenter trial. J Vase Surg 1991;13: 97. Malawer MM, Buch R, Khurana JS, et
67. Lepantalo M, Isoniemi H, Kyllonen L:
Nu· 423-427. al: Postoperative infusional continu-
Can the failure of a below-knee ampu-
)dict- 84. Jain AS, Stewart CP, Turner MS: Trans- ous regional analgesia (PICRA): A
tation be predicted? Ann Chir Gyna.ecol
ion. tibial amputation using a medially technique for relief of postoperative
1987;76:119-123.
based flap.JR Coll Surg Edinb 1995; pain fo llowing major extremity sur-
68. Eraklis A, Wheeler B: Below-knee am- 40:263-265. gery. Clin Orthop 1991;266:227-237.
[:
putations in patients with severe arte- 85. Weiss M: Bone treatment in amputa- 98. Elizaga AM, Smith DG, Sharar SR,
iph-
rial insufficiency. N Engl J Med 1963; tions and reamputations, in Myoplastic Edwards WT, Hansen ST: Continuous
in-
269:933-943. Amputation, Immediate Prosthesis and regional analgesia by nerve sheath
1
93; 69. Moore TJ: Amputations of the lower Early Amputation. Washington, DC, block has no effect on postoperative
extremity, in Chapman M (ed): Opera- US Government Printing Office, 1968, opioid requirements and phantom
tive Orthopaedics. Philadelphia, JB Lip- pp 61-65. limb pain fo llowing amputation. JRe-
11
pincott, 1988. 86. Ertl J: About amputation stumps. hab Res and Dev 1994;31:108-115.
7;22:
70. Brodie IAO: Lower limb amputation. Chirurgie 1949;20:212-218.

lntr
Becau
comm
stand
cal pr
comp,
This c
prescr
thesis.
based
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as fol
long-1
tient
limita
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ally r
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The ,
analy:
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that
Transtibial Amputation:
Susan L. Kapp, CPO
Int roduction
Because transtibial amputation is so whereas less active patients generally could indicate the need for a protec-
common, it is important to under- require a lightweight prosthesis with a tive interface such as a gel liner or
stand patient evaluation, biomechani- protective socket interface. A very thicker sock ply. Components that are
cal principles, prosthetic options, and athletic patient often requires not simple to don and doff are indicated
component availability for this level. only a strong, durable prosthesis but when upper limbs are also involved.
This chapter provides a framework to also specialized components. The clinic team, in consultation with
prescribe the most appropriate pros- the patient and family, may decide
thesis. An appropriate prescription is Geographic Location against prosthetic fitting in certain
based on a thorough physical exami- The patient's geographic location may cases. The energy requirements neces-
nation, history, and interview, as weU influence component selection. In an sary for functional ambulation may
as follow-up to achieve a successful extremely hot, humid climate where prove too great a risk for those with
long-term outcome. Unless the pa- perspiration is a concern, leather ma- severe cardiac conditions, for exam-
tient has other significant physical terials or rubber suspension sleeves ple. 1 In this context, a prosthesis i11-
limitations, prosthetic treatment of may be contraindicated. If the patient tended strictly for safe transfers
this level of amputation should gener- will have difficulty retmning for should suffice.
ally restore a patient to his or her follow-up, components that require
prior level of functioning. frequent maintenance are not practi- Employment
cal. Although prostheses help patients re-
Patient Evaluation turn to normal activities, employers
Time Since Amputation may need to make some accommoda-
The clinic team should thoroughly
analyze available patient information Time since amputation provides dues tions in job tasks for physical restric-
before considering specific socket about the weight-bearing capability tions associated with the amputa-
designs, suspension systems, compo- of the residual limb and the presence tion.213 Standing time should be
nents, and the indications and con- of postoperative edema. If the ampu- limited when feasible, and periodic
traindications for each. The pros- tation is long-standing and the pa- rest may be necessary, particularly in
thetic prescription should represent a tient is an experienced user, the per- the months immediately after ampu-
consensus between the health care formance of the previous prosthesis tation. Environmental barriers and
team and the patient. Several factors should be discussed in detail as the unstable standing surfaces should be
influence the prescription, as de- new prescription is developed. Often, minimized.4 Because prostheses need
scribed below. awareness of present problems or periodic maintenance, the patient
concerns can help avoid difficulties may require time off from work while
Activity Level with the new prosthesis. the component is being worked on,
Although age partially correlates with since most amputees cannot afford to
activity level, age alone is not useful Medical Condition have nmltiple well-fitting prostheses.
in determining the prescription. Ac- Certain pathologies may influence the Careful maintenance of the prosthesis
tive patients need a durable prosthesis choice of components. For example, will minimize the need for repairs
that will function for many tasks, limited sensation in the residual limb and future time lost from work.

forces can be applied more evenly to sta

over the surface area. 9 ther <
arnin
Soft Tissue draw,
If soft-tissue coverage is lim ited dis- stress
ta!Jy, the depth of the socket and the degre
fit of the distal pad are critical. lf sible
there is significant soft-tissue cover- prost
age djstally, as is common with the indic
long posterior flap amputation tech- join1t
nique, it will likely reduce as the limb may
atrophies from normal prosthetic use. triml
This is especially tr ue with the prefer- a su1
ence of many surgeons to discontinue for rr
the traditional beveling of the gas- and "
trocnemius and soleus muscle bel- ity (}
lies. 9 In this case, the limb may lose
contact with the distal pad. If this oc- Ran
curs, distal contact must be restored Ideal
to reduce limb edema in this area. achie
Figure 1 A, The bulbous distal end of this residual limb is typical in the early postoper- ion.
ative period. B, A muscle-balanced, cylindrical residual limb allows a greater distribution Skin Problems
mate
of weight-bearing forces. Even areas of the residual limb that tient
must bear weight in the prosthesis are fitted
tist to help the patient establish realis- unaccustomed to such large mechani-
Sports limit
tic and attainable goals, given the pa- cal forces and need time to adapt to Norr
Although some prostheses suitable for these new pressures. Persistent red-
tient's motivation and overall physical rang,
ambulation can also be used for some dening is a warning sign that bruises,
condition. Age should not be a factor degn
recreational sports, increasingly pa- blisters, or excoriations may eventu-
because the elderly appear to have no initia
tients request a prosthesis specifically ally develop. Without pressure relief,
greater difficulty in adjusting psycho- quatc
designed for sports. Specialized trans- areas of excessive loading can develop
tibial prosthetic components and logically to physical activity with a assoc
into pressure ulcers that extend deep
techniques are available to facilitate prosthesis than adults as a whole. ion "
into the subcutaneous tissues. Many
swimming, skiing, jogging, and most Transtibial amputees may be told that for s:
factors increase the risk of skin break-
other sports. 5 Exercise is key to good returning to their preamputation am- knee
down, including reduced elasticity of
health, most especially for those with bulatory level is a very reasonable COIDJ
aged skin; moisture that tends to in-
disabilities. 6 Walking to increase en- goal, regardless of age. 8 mern1
crease friction; heat, which will hasten
dw·ance can prevent further weaken- 25° r
Shape of the Residual Limb blister formation; and skin that is di-
ing for individuals with transtibial cult.
rectly over bone.
amputations, particularly in the geri- The shape of the residual limb may be thel
Skin problems result from an ill-
atric population.7 Dynamic-response an indicator of potential fitting prob- tract
fitting prosthesis and, therefore, can
lems. A bulbous residual limb, which Prev,
feet and vertical shock pylons may be resolved by socket or alignment
is often present shortly after amputa- visec
help patients return to a more active modifications or by a new fittin g. Al-
tion, has a larger circumference dis- to tr,
lifestyle. lergic reactions can be remedied by
The goal of many rehabilitation tally than proximally. If this difference switching to an alternate material. Cor
programs is to help the patient be- is large enough, the patient will fmd it Skin tolerance for sustained pressure
come physically active and restore difficult to don or doff the prosthetic has been shown to increase over time
Mu
10
function to at least the level of activ- socket (Figure 1, A). A conical resid- in patients with spinal cord injury. The
ity before the amputation. This goal is ual limb is typical of an individual It is believed that gradually increasing achi(
especially important for the traumatic who is a long-term user and will gen- the use of a new prosthesis will ease the
amputee. erally not present a fitting problem, skin adaptations to pressure. l<ne(
although the characteristic atrophied abrn
Patient Goals limb m usculature may limit soft- Condition of the Knee Joint ion,
The prosthesis design should be tai- tissue weight bearing. A cylindrical Ligamentous laxity in the coronal ical
lored to meet the patient's personal residua] limb (Figure 1, B) is the ideal (frontal) or sagittal plane may necessi- pros
goals. It is important for the prosthe- shape because pressure and stabilizing tate modifications in prosthetic design requ

Chapter 39: Transtibial Amputation: Prosthetic Management SOS
~nly to stabilize the joint and prevent fur-

ther damage. A thorough physical ex-
amination, including the anterior
Quadriceps
drawer test and a knee varus/valgus bar
dis- stress test, is essential to determine the
the degree of clinical laxity. It is often pos-
.I. If sible to control mild laxity th rough
,ver- prosthetic alignment. Increased laxity
the indicates the need to cross the knee
ech- joint to obtain adequate stability. This
]jmb rnay be achieved by extending socket
. use. trimlines with a supracondylar design,
·efer- a supracondylar-suprapatellar design
turne for moderate instability, or steel joints
gas- and a thigh corset for severe knee lax-
bel- ity (Figure 2) .
· lose
LS oc- Range of Motion
tored Ideally, the patient should be able to
a. achieve fuJl knee extension and flex-
ion. Normal knee range is approxi-
mately 145° of flexion. Although a pa- A B
> that tient with limited knee range can be
;is are fitted with a prosthesis, functional Figure 2 The PTB supracondylar-suprapatellar socket aids in sagittal and coronal kn ee
:hani- limitations should be anticipated. stability. A, Medial view. B, Anterior view.
apt to Normal gait requires a functional
t red- range of 0° to 70°, with the h ighest
ruises,
degree of flexion occurring du ring
Staging of Care and fitted specifically to the patient's
ventu- limb size. Easier to apply for both the
initial swing. 11 ' 12 Although 70° is ade- Once the wound has healed ade-
relief, patient and caTegivers, these devices
quate for normal gait, Laubenthal and quately, rehabilitation focuses on
evelop consist of a series of elastic bands
associates 13 observed that 83° of flex- shaping the residual limb for pros-
i deep sewn together to form a cylinder. The
ion was needed fo1· stair climbing, 93° thetic fitting and increasing weight-
Many prosthetic shrinker is replaced with a
for sitting, and 106° for shoe tying. A bearing capacity. These goals are ac- smaller sized shrinker as the residual
break·
knee flexion contracture can be accomplished with the help of elastic
city of limb decreases in volume. Disadvan-
commodated in the prosthetic align- bandages or prosthetic shrinkers, tages of elastic bandages and sh.rink-
to in-
ment, but a contracture greater than rigid dressings, postoperative prosthe- ers are that they do not protect the
hasten
25° may make prosthetic fitting diffi- ses, and preparatory prostheses. Cou- limb, must be reapplied several times
tis di-
cult. The shorter the residual limb, pled with gait training, physical ther- each day, and do nothing to prevent
the higher the degree of flexion con- apy, and close supervision by the knee flex ion contractures. For the re-
an ill·
,re, can tracture that can be accommodated. 14 cfu1ic team, these treatments prepare cent amputee, shrinkers or elastic
Preventing joint contractures is ad- the lin1b for definitive prosthetic fit- bandages should be worn whenever
~nment
vised because they are often difficult ting. Elastic bandages are usually ap- the patient is not wearing the pros-
ing. Al·
iied by to treat o nce they have developed. plied as the postoperative dressings thesis, a rigid dressing, or some other
1aterial. al"e removed. T hese compression compressive device (Figure 3).
Condition of the Thigh treatments help reduce funb edema,
nessure Midthigh-length rigid dressings
,er time
Musculature thereby promoting healin g and de- applied immediately after surgery
• tO
11Jury. The transtibial amputee cannot creasing pai n. For patients with control edema and red uce pain. 15 Th e
creasing achieve a smooth, controlled gait if wound complications, delayed heal- removable rigid dressing was de-
~ill ease the quadriceps muscles are weak. ing, or other circumstances that delay signed to allow frequent wow1d in-
Knee e>.'tensor weakness can result in prosthetic fitting, an elastic bandage spection and provide progressive limb
abrupt knee flexion, absent knee flex- may be the most p ractical a nd eco- shrinkage by the addition of socks
! Joint ion, and an uneven step length. Phys- nomical form of residual limb condi- (Figure 4) . The removable rigid dress-
coronal ical therapy is an integral part of tioning. Residual limb shrinkers may ing may be particularly effective for
· necessi· prosthetic management and may be be used in place of elastic bandages. patients with diabetes mellitus or de-
ic design required for strengthening. They are provided by the prosthetist layed wound healing. 16

adj us
Prosthetic
It is
sock
progt
Supracondylar withi
cuff tatior
Suspension
A
__ _,.,,
·~
sock tive J
activi
ance,
chan,
in so
Synthetic
or plaster tinue
cast cisio1
ting
on tr
tient
level,
sidm
youn
Figure 3 The residual limb shrinker can be applied using a donning ring t o ease the dis· Figure 4 The removable rigid dressing is worn
comfort of application. easily applied, protects t he residual limb, read]
and can be removed for suture line in- cant
spect ion.
Postoperative prostheses were in- the J
bad I
troduced by Marian A. Weiss, PhD, of
sufficiently to allow donn ing and mod
Poland and further refined in the
doffing of a prosthetic socket (ie, weel<
United States by Ernest Burgess, MD,
when the circumference of the proxi· with
in the 1960s.17 Immediate postopera-
mal limb at the tibial tubercle is larger walk
tive prostheses are applied immedi-
than the distal limb circumference). 4 to
ately after amputation; "early" pros-
Depending on the pace of residual less I
theses are applied within a few days
limb atrophy, the preparatory pros- caus,
after amputation. They offer all the
benefits of rigid dressings and permit thesis may be worn for a few months limb
or as long as a year before tl1e socket lized
limited weight bearing and supervised
early ambulation. The postoperative is replaced or definitive fitting is rec- T
prosthesis is essentially a rigid dress- om mended. A preparatory prosthesis defu
ing that extends to midthigh and is is generally constructed on an en· goal
suspended by a waist belt to which a doskeletal pylon, permitti ng align· pros

prosthetic pylon and foot are attached ment changes at any time. This is a prep
(Figme 5) . considerable advantage because the it, O
Given the possible complications of needs of the patient can be constantly pen.c
this treatment, success depends pri- reassessed and accommodated as the mg 1
marily on the skills of the clinic team. ability to use the prosthesis improves. A
As the cast loosens, it must be removed Once fitted with a preparatory pon,
and a new one applied after 7 to prosthesis, the patient should pro· avail
10 days. Two or th ree cast changes may gress in physical therapy to full weight tage
be needed until the patient is ready for bearing. In addition to receiving gait coni
a preparatory prosthesis. training, the patient should be in· com
Prefabricated postoperative devices structed in the use of prosthetic neec
are now available and are appropriate socks, the application of shrinkers or
Figure 5 The immediate postoperative

in many instances (Figure 6). They are elastic wraps, residual limb hygiene, So
adjustable and elimi nate the need for and how to inspect the limb for any
prosthesis allows early, supervised, touch- Pa1
down wei ght bearing and ambulation. recasting as limb volume decreases. 18 sign of excessive pressu re. The patient
A preparatory or intermediate should also be educated about falls Soi
prosthesis fitting can begin when the and how to reduce the risk of fall· To
patient's residual limb has atrophied ing. 19 Alignment and socket fit are (PT

Chapter 39: Transtibial Amputation: Prosthetic Management 507
adjusted by the prosthetist as needed.

It is not unusual for the patient to
progress tilrough several sockets
lar within the first year following ampu-
tation.
,n A patient's readiness for a defini-
tive prosthesis varies, depending on
activity level, weight-bearing toler-
ance, and limb shrinkage. Atrophic
changes may stabilize after 4 months
in some cases but more typically con-
tinue for 12 montl1s or more. The de-
cision to proceed with definitive fit-
ting is largely subjective and is based
on tile overall perception that tile pa-
tient has reached a plateau in activity
level, prosthetic wearing time, and re-
sidual limb volume. For example,
young, active amputees who have Figure 6 This prefabricated postoperative socket is removab le for wound inspection
ing is worn a preparatory prosthesis are and adjustable for volume f luctuations. A pylon and foot can be added.
limb, ready for definitive fitting when they
ie in- can tolerate full weight bearing, wear
of ilie patient's residual limb and then porate a soft, protective pad. The PTB
the prosthesis all day, and have not
modified to achieve an intimate, total-contact socket is suitable for
had to add prosilietic socks to accom-
total-contact fit over tile entire sur- many transtibial amputations, except
and modate limb shrinkage for some
face of the residual limb. There is an in some postoperative prostheses or
t (ie, weeks. In contrast, elderly patients inward contour or "bar" that uses the when pathologic conditions require
,roxi- witil other healtil problems may use a
patellar ligament as a partial weigbt- an alternative socket.
larger walker and wear the prosthesis only
bearing surface. The term "patellar The total-contact teclrniques that
ence). 4 to 5 hours daily but may neverthe-
tendon-bearing" can be misleading, were introduced witil the develop-
sidual less be ready for definitive fitting be- however, because the patellar ligament of tile PTB socket were a radical
pros- cause tileir activity level and residual ment is not the major weight-bearing change from the previous open-end
1onths limb volume changes have been stabi- surface used by this type of socket. socket designs. Total contact means
socket lized. The medial and lateral socket walls that all areas of tile limb are to have
is rec- The design and components of the extend proximally to about the level some contact, but weight bearing is
sthesis definitive prosthesis are based on the of the adductor tubercle of the femur. limited to pressure-tolerant anatomy.
in en- goals of tl1e patient. The definitive Together, they control rotation, con- Altilough the entire limb surface
align· prosthesis may closely resemble the tain soft tissue, and may provide should have contact to prevent
us is a preparatory prosthesis that preceded some mediolateral knee stability. The edema, not all surfaces carry weight
1se the it, or it may differ dramatically, de- medial wall is modified with a slight or equal loads.20
tstantly pending on the goals established dur- undercut in the area of the pes anseri-
as the ing rehabilitation. nus on tile medial flare of the tibia, Total Surface-Bearing
.proves. A wide variety of prosthetic com- providing significant weight bearing Socket
,aratory ponents, materials, and techniques is on this major, pressure- tolerant sur- Total surface-bearing (TSB) theory
1d pro· available, and every option has advam- face. The lateral wall provides a relief proposes that pressure can be distrib-
l weight tages and disadvantages that must be for the fibular head, supports the fib- uted more equally across the entire
ing gait considered to provide the optimum ular shaft, and acts as a counterpres- surface of ilie transtibial residual limb
be in· combination for each patient's unique sw·e to the medial wall. The posterior than wiili a PTB socket. In principle,
osthetic needs. wall is usualJy designed to apply an even ilie pressure-sensitive areas can
11kers or anteriorly directed force to keep the carry some portion of the load. In-
hygiene, patellar ligament on the bar. The pos- creasing the pressure on tile tissues
for any
Socket Design
terior wall is flared proximally to al- around these areas can relieve bony
~ patient
Patellar Tendon-Bearing low comfortable knee flexion for sit- ridges. 2 1•22 TSB advocates often sug-
out falls Socket ting and to prevent excessive pressure gest use of a special liner material to
. of fall· To create a patellar tendon-bearing on the hamstring tendons. The distal help disperse the forces applied to the
t fit are (PTB) socket, an inlpression is taken portion of the PTB socket may incor- residual limb.
Amer-ican Academy of Orthopaedic Surgeons

regulate shear stress on the skin. The they

advantages of soft sockets are that creas,
they provide a soft, protective socket sis, a
interface, have "rebound" in the insert becal
that may improve circulation by pro-
viding a "pumping action" and inter- Flex
mittent pressure over bony promi- Rigi1
nences, and are easily modified to Man)
adj ust for atrophy in the residua] sockt:
limb. The disadvantages of these fram,
sockets are that the materials deterio- from
rate over tin1e, they are not as sanitary rial, ,
as hard sockets because the inserts inate
tend to absorb fluids over time, they mate
increase bulk around the residual sockf
limb, they may compress over time beari
resulting i11 loss of fit, and they in- press
crease the overall weight of the pros- prorr
thesis. quiri
Figure 7 Polyethylene foam liners help Figure 8 Residual limbs with skin t hat is only
protect the skin and provide shock ab- susceptible to breakdown can be pro- Gel liners techr
sorption during ambulation. tected more effectively with a gel inter-
Elastomeric liners, made of silicone or comf
face.
similar materials, are often recom- in en
mended for patients whose skin is
Hydrostatic Socket ses.
of these sockets are that they require compromised by grafted areas or ad- weigl
In theory, a hydrostatic socket trans- herent scar tissue (Figure 8). Addi-
extra skill in casting and modifica- ered
mits pressure equally to every point tion, are difficult to fit over sharp tional factors that )jmit the weight-
within a socket to minimize localized dissiJ
bony contours or sensitive residual bearing capability of the residual acco1
weight-bearing areas. 23 The hydro- limbs, and they are not as easily mod- limb, such as short length or a conical
static socket includes a gel liner to They
ified as a socket with a soft insert. shape, may also be indications for cons;
help reduce peak pressures. There is cushioning liner materials. These lin- the c
little statistical evidence to support Soft Inserts ers are usually worn directly against
any specific socket design theory, but Soft inserts are fabricated over the the skin and move with it, thus reduc·
there has been a clear evolu tion in modified cast to fit inside the socket. ing friction and shear. 25' 26 Several hy- Bic
thinking in recent decades to mini- They act as an interface between the giene problems are associated with Pr<
mize local forces as much as possible. limb and socket to add comfort and the elastomeric liners, specifically
itching, perspiration, eruption, and To t:
protection by moderatin g impact and
Socket Variants odor. 27 T hese problems can be re- pros1
shear. They are often fabricated from
Hard Socket d uced by meticulous daily cleansing func
a 5-mm polyethylene foam material
The hard socket is made from rigid of the skin and liner, but elastomeric out
(Figure 7). Soft inserts are recom-
material and has specific advantages liners should be not considered if a this
mended for patients with peripheral
and disadvantages. This variant is in- vascular disease; with th.in, sensitive, patient is unwilling to maintain hy- ofth
dicated primarily for maximum dura- or scarred skin and sharp bony prom- giene. thq
bility when the residual limb has good inences; or with peripheral neuropa-
Distal Pads Init
soft-tissue coverage and no sharp thy. Bilateral transtibial amputees
bony prominences. It is not com - may prefer inserts to protect the distal To improve overall comfort and to Duri
monly used for residual limbs with help control edema, the distal portion func
portion of the tibia when they rise
th.in skin coverage, scarring, skin from a chair or climb stairs and in- of PTB sockets generally incorporates tion.
grafts, or a predisposition to break- clines. The added protection of a soft a soft p ad made of silicone or poly· the i
down. The advantages of hard sockets insert may also benefit the highly ac- ethylene foam. These pads ensure to- grou
include that they are perspiration re- tive patient. Liner materials are cho- tal contact distally, provide increased are t
sistant, less bulky than sockets with a sen based on their elastic properties comfort, protect the distal portion of the
soft insert, easy to keep clean, and du- and frictional characteristics with the the residual limb when it settles into too
skin.2 4 A balance must be sought be- the socket as a result of volume loss, to g
rable. In addition, reliefs or modifica-
tween the material's ability to reduce and facilitate future modifications of n1on
tions can be located with precision
stress over bony prominences and the distal end of the socket. However, strai
with these sockets. The d isadvantages
American. Academy of Orthopaedic Surgeons

'he they also add fabrication time, in- Loading Response As the tibia continues to advance,
1at crease overall weight of the prosthe- body weight is transferred entirely
During the loading response phase,
ket sis, and are considered less hygienic the foot must provide control of onto the forefoot and the metatar-
ert because they absorb fluids. plantar flexion. Because the ground- sophalangeal (MTP) joints. The pros-
ro- reaction force vector is posterior to thetic foot must also support the ter-
:er- Flexible Inner Sockets With minal stance phase and should
the ankle joint, a plantar tlexion mo-
mi- Rigid External Frames simulate MTP dorsiflexion.
ment occurs during loading response.
to Many patients prefer a flexible inner In the human foot and ankle, this
lual socket that is inserted into a rigid Preswing
moment is controlled by the ankJe
1ese frame. The inner socket is fabricated During preswing, the foot must pro-
dorsiflexors. These muscles contract
rio- from polyethylene or a similar mate- vide support for transfer of body
eccentrically and allow smooth, con-
tary rial, and the frame is made from lam- weight to the opposite side. After both
trolled plantar flex:ion of the foot to
.erts inated plastic or a rigid thermoplastic lin1bs are supported, the weight of the
tl1e floor. As the foot progresses to the
they material. The frame supports the body is taken off of the preswing leg
floor, the tibia begins to advance for-
:lual socket over the primary weight- and transferred to the opposite side.
ward, and limb progression is contin-
wne bearing areas, whereas the more ued. Proper control of plantar flexion
The prosthetic foot should provide
. m- pressure-sensitive areas, such as bony enough support to help maintain bal-
allows the tibia to advance at the
,ros- prominences and soft tissues not re- ance and encourage smooth transfer
proper velocity. Prosthetic plantar
quiring rigid support, are enclosed of weight to the sound side. Ankle-
tlexion can be affected by the stiffness
only in the flexible socket. This foot function and prosthetic align-
of the heel portion of the foot com-
technique often results in a more ment during this phase wiJJ affect the
ponent. Generally, the stiffer the pros- degree of impact the contralateral
1e or comfortable socket and can be used thetic heel, the larger the plantar flex- foot experiences.28•29 This may be
:om- in endoskeletal or exoskeletal prosthe-
in is ion moment that is generated. particularly important for patients
ses. These sockets decrease overall
rad- with compromised vascular and neu-
weight of the prosthesis, are consid- Midstance
\ddi- ered more comfortable, improve beat rologic systems, putting the surviving
:ight- At midstance, the prosthesis must foot at risk.
dissipation, and can be replaced to provide controlled advancement of
;idual Rapid knee flexion at this point ef-
accommodate anatomic changes. the tibia. The momentum of the
mi cal fectively shortens the leg and prepares
They are, however, difficuJt and time- swing limb and forward fall of the
.S for it to have adequate clearance during
consuming to fabricate and may lack body's weight create a dorsiflexion
;e lin- swing phase. The toe-break area of
the cosmesis of a hard socket. torque that takes tl1e tibia from an 8°
gainst the human foot is at the MTP joints.
·educ- plantar flexed position to a 5° dorsi- This allows the foot to roll over at the
·al hy- Biomechanics of flexed position throughout the stance metatarsal heads instead of tl1e tips of
phase. Both the heel and forefoot re- the toes. The prosthetic foot will also
with Prosthetic Feet main in contact with the floor the en-
.fically have a toe break to provide the same
L, and
To ensure efficient ambulation, the tire time. The foot and ankle provide smooth rollover motion, or the design
be re- prosthetic foot should mimic the an ankle rocker that allows forward of the foot will allow forefoot flexibil-
ansing functions of the human foot through- progression of the leg. The gastrocne- ity to accomplish the same goal. This
)meric out the gait cycle to the degree that mius and soleus muscles are active in forefoot flexibility may also help re-
:d if a this is feasible. The function required controlling the speed of this progres- duce loading on the sow1d limb by
,in hy- of the prosthesis during each phase of sion and in maintaining stability. 11 minimizing the elevation of the cen-
the gait cycle is described below. The prosthetic foot simulates this ter of gravity. 30
muscle pattern by providing stance
Initial Contact phase stability through a rigid, semi-
and to During initial contact, the primary rigid, or flexible keel within the foot. Foot Selection
?ortion function of the foot is shock absorp- A thorough understanding of pros-
po rates tion. The prosthetic foot must absorb Terminal Stance thetic foot biomechanics is essential
,r poly- the impact of the heel contacting the During terminal stance, the foot must because foot selection alone has a
;ure to- ground and minimize the forces that provide controlled heel rise and pro- profound impact on the ultimate suc-
1creased are transferred to the residual limb. In gression onto the forefoot. In this cess or failure of a prosthesis. Five
rtion of the case of the transtibial amputee, phase, the foot and ankle are essen- variables must be considered when
les into too much shock absorption may fail tially locked into position to provide selecting a prosthetic foot: alignment
me loss, to generate the normal knee tlexion heel rise as tibial advancement con- and length of the toe lever arm, width
tions of moment and result in an unnatural, tinues. The forefoot now becomes tl1e of the keel, flexibility of the keel,
[owever, straight-knee gait. rocker over which the tibia advances. durometer of the heel cushion, and fit

ensure that socket alignment in the

sagittal plane is not altered and tl1at
the keel of the foot maintains the cor-
rect position with respect to the floor.
Once a prosthesis has been aligned
and fabricated, the patient should not
significantly increase the height of his
or her shoe heel unless an appropriate
wedge is added inside the shoe. Re-
cently available ankle-foot assemblies
that can be adjusted for different heel
Figure 9 An adjustab le-heel foot accommodat es variations in the heel height of differ- heights should be considered if fre-
ent shoes. This eliminat es the need to change feet on the prosthesis. A1
quent changes in heel height are an-
tit
ticipated (Figure 9).
tu
of the prosthetic foot within the shoe. creased shock absorption during the The material and contours of the
The spatial relationship between loading response. Optimizing heel- shoe heel can make a significant dif- C1
ference in the way the prosthetic tit
the foot and socket is referred to as cushion density requires balancing
alignment and influences both the shock absorption against the mo- wearer ambulates. For example, a soft
function and comfort of the prosthe- ments acting to flex the knee. As in crepe heel enhances the shock absorp-
D
sis. Optimum foot position is deter- similar prosthetic decisions, the tion qualities of a foot. In compari-
ot
mined during the fitting process with choice must be based on the patient's son, a hard leather or rubber heel will
linear movements in the sagittal and needs. tend to increase knee-flex.ion moment
coronal planes, inversion/eversion, Heavier patients are more Likely to during the loading response. If such
dorsiflexion/plantar flexion, and foot require a firm heel cushion to provide heels present a problem, it is appro- Fig ur
rotation. a sufficient knee flex.ion moment dur- priate to round or bevel the posterior
The manufacturer determines keel ing the loading response. Lighter pa- corner of the heel, thereby decreasing
bern
width. A wider keel provides greater tients will generally require medium- the knee moment at heel strike. Wom-
umq
or soft-density heel cushions to avoid en's high heels may compromise
mediolateral stability during stance cha:r:
creating an excessive knee-flex.ion stance phase stability and are not rec-
phase by widening the base of sup- two
moment. Very active patients may ommended for weak, debilitated pa-
port within the shoe. For example, alig:r
prefer a firm heel cushion because tients.
external-keel feet and some flexible-
more rapid cadences increase net Forcing a solid-ankle foot into a Soc
keel feet have wider keels than do
loading on the foot. Elderly patients tight-fitting shoe diminishes the abil-
other feet. The difference, however, is The
ity of the foot to compress and bend
rarely significant enough to be the or household ambulators often re- coru
during ambulation. It is always better
sole rationale for prescription but quire soft heel cushions to limit knee- and
to fit the shoe slightly loose on the
may be significant in cases where flexion moment and maximize shock fore,
foot so that maximum flexibility is
coronal plane stability is a concern. absorption. fom
maintained.
A flexible keel offers a smoother The prosthetic foot is designed to thro
Although function of the pros-
gait with a less pronounced transition function under the sti·ess of ambula- The:
thetic foot is of primary concern to
at the toe break than does a rigid keel. tion. It compresses, rebou nds, flexes, duri
the prosthetist, the importance of ap-
To increase resistance of the forefoot and extends as it operates throughout Succ
pearance cannot be overlooked. The
during late stance phase, the flex:ible- the gait cycle. With the exception of requ
design of a particular foot may en-
keel/dynamic-response foot can be postoperative feet and those designed duri
hance or dimin ish its cosmetic ap-
moved anteriorly or slightly plantar for barefoot ambulation, prosthetic and
peal.
flexed during dynamic alignment of feet are designed to fit inside a shoe. It
the prosthesis. Stiffer keels may offer should not be surprising, then, that Disi
the function of a prosthetic foot can Socket and To/1
greater stability during stance.
be enhanced or decreased by the shoe
Tiss
T he heel cushion absorbs shock Alignment In ti
and helps initiate knee flex.ion during it is fitted with. At times, it may be
the loading response. Increasing heel necessary to modify the foot or the
Biomechanics cent
stiffness increases the knee-flex.ion shoe to ensure optimum function. Successful fitting of a transtibial pros- coa1
moment at loading response and de- Heel height is the single most im- thesis requires a thorough under- an (
creases shock absorption. Conversely, portant factor in shoe fit related to standing of the biomechanical vari- rna:x
decreasing heel stiffness results in a foot function . It should match the ables involved and the ability to twet
smaller knee-flex.ion moment and in- built-in heel rise of the foot. This will achieve an appropriate compromise Sod

the
hat
:or-
:>or.
ned
not
' his
:iate
Lateral
Re- tibial
:ilies flare
heel Head of Hamstring
fibu la and tendons
fre- peroneal
: an- Anterior
tibial nerve
tubercle
f the
: dif- Crest of
tibia
hetic
I soft
;orp- Distal end
of fibula
.pari- of tibia
:l will
ment A 8 c
such
ppro- Figure 10 Areas requ iring pressure relief in a PTB socket. A, Anterior view. 8, Lateral view. C, Posterior vie'w.
terior
~asing
between these variables to meet the plicated by differences in tissue dis- ments at the joints of the lower limb.
#om-
unique needs of each patient. Biome- placement and tissue pressure toler- Forces are similar during amb ulation
omise
chanical factors can be divided into ances. For example, some bony with a prosthesis, but they are applied
>t rec-
two broad categories-socket fit and portions of the residual limb, such as through the prosthetic socket to tbe
:d pa-
alignment/foot function. the distal tibia or the fibular head, residual limb. Forces on the residual
cannot be compressed as much as limb, specifically anteroposterior and
into a Socket Fit soft-tissue areas. mediolateral forces, must be managed
e abil-
The prosthetic socket is the primary Most fitting problems can be re- to achieve socket comfort and prevent
l bend
connection between the residual limb solved through appropriate socket de- skin breakdown. The greatest antero-
better
and the prosthesis. It must bear the sign. To apply greater forces to posterior forces are generated from
on the
force of body weight and cushion the pressure-tolerant areas and less to heel strike to foot flat while a power-
ility is
forces applied to the residual limb pressure-sensitive areas, tissues are se- ful knee-flexion moment exists. Knee
through contact with the soclket. lectively loaded over weight-bearing stability is maintained by contraction
pros-
These forces are continually changing surfaces and relieved over sensitive ar- of the quad1·iceps. The resulting
:ern to
during dynamic use of the prosthesis. eas. Areas within the socket that re- forces between the socket and residual
: of ap-
Successful distribution of these forces quire relief may include the tibial limb are concentrated on the antero-
:d. The
requires careful attention to detail crest, tibial tubercle, lateral tibial distal portion of the tibia and postero-
iay en·
during patient evaluation, casting, flare, distal tibia/fibular head, pero- proximal soft tissue (Figure 12). The
:tic ap·
and socket modification. neal nerve, hamstring tendons, and socket, therefore, must distribute
the patella (Figure 10). Pressure- pressure evenly in the popliteal area
Displacement and Pressure tolerant areas may include the patellar and relieve pressure anterodistally, as
Tolerance of Residual Limb ligament, medial tibial flare, medial well as provide anterior, medial, and
Tissues (Total Contact) tibial shaft, lateral fibular shaft, and lateral counterpressures to prevent
In theory, ensuring that every square the anterior and posterior compart- excessive pressure over the distal end
centimeter of the residual limb is in ments (Figure 11). of the t ibia.
ial pros- contact with the socket and is sharing The greatest mediolateral forces
under- an equal portion of the load would Modification for Dynamic occur during single-limb support on
:al vari· maximally reduce the pressure be- Forces the prosthetic side. With normal foot
>ility to tween the residual limb and the In normal human locomotion, inset, forces are generally increased
lproroise socket. In actual practice, this is com- ground-reaction forces produce mo- over the proximomedial and distolat-

smoc
i.ng c
strikE
vatur
con ta
Pr
Patellar
will 1
ligament
tolen
provE
istics
Posterior smoc
Medial compartment muse
tibial mech
flare
the p
force.
Lateral shaft
of tibia of fibula Pr
Anterior
ing I,
compartment
la ten
helps
mom
A B c op tin
flare
Figure 11 Pressure-tolerant areas in a PTB socket. A, Anterior view. B, Lateral view. C, Posterior view. foot ·
cond:
open wounds.3 1 Patients with sensi- short
tions to prevent this problem include
tive skin, such as burn patients or as m ·
relief for the distolateral aspect of the
bony
fibula, lateral stabilizing pressure those with diabetes mellitus, may be
especially susceptible.
Fo
along the shaft of the fibula, and lat-
flare
eral stabilizing pressure over the ante- A soft socket insert or a nylon
narrc
rior compartment (pretibial m uscle sheath worn directly over the skin can
pend
group). reduce these forces. Rotation units or resid1
Torque and shear may also present "torque absorbers" are another option genu
prosthetic problems within the to mitigate shear. These components stanc
socket. If torque is excessive, the ten- are commonly used in transtibial bette:
dency of the socket to rotate i.n rela- prostheses if the patient wears the gait i
tion to the residual limb may cause prosthesis during activities such as decre
discomfort, skin breakdown, or gait golfing that generate significant becal
deviations. torque or if the patient has fragile limitc
A certain am ount of shear is un- skin. Tl
avoidable because some motion be- mine
Figure 12 Areas of concentrated pres·
tween the socket and the underlying Alignment/ Foot Function thesii
sure during ambulation.
tissues will always occur. Shear occurs Correct dynamic alignment is deter· of th
in all three planes whenever the mined by the prosthetist as the pa· perio
eral aspects of the residual limb. Al- socket moves in a direction opposite tient ambulates on an adjustable not 1:
though these forces can be reduced if to residual limb motion. For example, alignment unit. This unit allows an- hibitri
the prosthetic foot is moved laterally, if the suspension is too loose, the teroposterior foot positioning, an- limb-
in most cases the prosthetic socket prosthesis tends to drnp away from teroposterior tilting of the socket, femo
must accommodate these forces. the limb during swing phase, only to mediolateral foot positioning, me- be cc
Proxirnomedial forces are not a sig- be driven back to its correct position diolateral tilting of the socket, height the b
nificant problem because they are fo- during loading response. This motion adjustment, and rotation of tl1e pros· thro1:
cused on the pressure-tolerant medial creates shear stress between the resid- thetic foot. feedb
femoral condyle and medial tibial ual limb and the socket. These shear Proper anteroposterior positioning asm1
flare . But distolateral forces can create stresses can cause cell separation of the prosthetic foot will distribute exces
excessive pressure on the transected within the epidermal layer, leading to weight evenly between the heel and Pr
end of the fibula. Socket modifica- blisters and, if the epidermis is thin, toe portion. This will result in a both

Chapter 39: Transtibial Amputation: Prosthetic Management 51 3
smooth, energy-efficient gait, includ- Prosthetic toe-out refers to the angle and no other complicating health
ing controlled knee flexion after h eel between the line of net forward pro- problems. Before the amputation, the
strike, smooth rollover without recur- gression and the medial border of the woman worked part time in the local
vatwn, and heel-off before initial heel prosthetic foot. A transtibial prosthe- library. Her goals were to ambulate
contact on the contralateral foot. sis is initially aligned so that the me- unassisted and without limitation.
Proper anteroposterior socket tilt dial border of the foot is parallel to She lived with her husband and one
will load those areas that are pressure the line of progression. This results in young grandchild and had a relatively
tolerant. Proper flexion not only im- a slight external rotation of the pros- sedentary lifestyle.
proves the weight-bearing character- ilietic foot, thereby approximating the
istics of the socket but also creates a 5° to 7° of normal anatomic toe-out. Prescription Recommendation
smooth gait; places the quadriceps This position may need to be altered, The woman received an initial trans-
muscles "on stretch," giving tl1em a however, during static and dynamic tibial prosthesis wiili a PTB socket de-
mechanical advantage for controlling alignment so that foot position dur- sign to load the weight-tolerant tis-
the prosthesis; and limits recurvatum ing ambulation visually matches that sues and unload the weight-intolerant
forces during late stance. of ilie sound limb. areas. It is a total-contact prosiliesis
Proper mediolateral foot position- Foot rotation can also affect pros- to improve proprioception, with a
ing loads proximomedial and disto- thetic function . T he keel of the foot is custom silicone distal-end pad to en-
lateral aspects of the residual limb. It a lever arm. During the stance phase courage venous return and prevent
helps create a normal genu varum ilie tendency of ilie body to fall over distal edema. The soft silicone end
moment at midstance and provides the foot is resisted by the counterforce pad will also accommodate some dis-
optimum loading of the medial tibial of iliis anterior lever arm. Rotation of tal migration of the residual limb
flare during stance phase. Optimum ilie foot, therefore, directly affects the without undue end pressure. The
fo ot inset is related to the length and length of the lever arm created and socket is made of acrylic resin for re-
condition of ilie residual limb. A ilie direction of ilie force. The net ef- duced weight and increased strength
short residual limb may not tolerate fect of externally rotating the foot and to facilitate socket adjustments. A
ensi-
as much because of the reduction in may be to increase stability by widen- neoprene suspension sleeve provides
:s or
bony lever arm. ing the base of support. Excessive foot simple, effective suspension. A flexible
LY be
Foot inset loads the medial tibial rotation has been shown to adversely keel foot will absorb some of the im-
flare appropriately, gives ilie gait a affect stance and swing time as well as pact of walking and make rollover
1ylon
narrow base, and decreases energy ex- step length. 32 Although slight external easier. The endoskeletal components
1 can
penditme but increases torque on ilie rotation of the foot may be beneficial, are lightweight and adjustable for
its or
residual limb because of the normal there is a cosmetic tradeoff if ilie toe- postfabrication alignment changes
ption out attitude of the prostl1esis does not that will inevitably be necessary as the
genu varum moment created at mid-
nents stance. It also gives the prosthesis a match that of the contralateral limb. woman's gait improves. She received
:tibial better cosmetic appearance. A wide gel sheaths to wear directly against
s the gait increases energy expenditure but the skin to reduce shear on ilie resid-
:h as decreases torque on ilie residual limb
Case Studies ual limb and decrease the chances of
ficant because the genu varum moment is Case Study 1 skin breakdown. She was also given
'ragile limited or eliminated. A 63-year-old woman 5 ft 6 in tall and one-, three-, and five-ply prosthetic
The most convenient way to deter- weighing 145 lb underwent a trans- socks to accommodate volume fluctu-
mine the correct height of the pros- tibial amputation secondary to com- ations in the residual limb.
in tllesis is through clinical comparison plications of diabetes mellitus 6 weeks
deter- of the iliac crests or the posterior su- earlier and at the time of presentation Case Study 2
1e pa- perior iliac spines. This approach may was wearing a prosthetic shrinker. A 26-year-old man 5 ft 10 in tall and
LStable not be appropriate if the patient ex- Her preprosilietic physical therapy in- weighing 160 lb was wearing an inter-
vs an- hibits pelvic obliquity, congenital cluded training in transfers, use of a mediate prosthesis 9 months after un-
~, an· limb-length discrepancy, or unilatreral walker, maintenance of range of mo- dergoing a midlength transtibial am-
;ocket, femoral shortening. Such cases must tion, and muscle strengthening. The putation of the right leg as a result of
, me- be considered individually, and often distal limb circumference was 2 cm a crush injm-y incurred on a con -
height tlle best indicator of correct length is smaller than the pro.>.imal limb cir- struction job site. The residual limb
: pros- tllrough gait analysis and patient cumference. The suture line was well had a well-padded distal end because
feedback. Proper height will result in healed, and ilie woman was ready for the gastrocnemius and soleus muscles
ioning a smooth and symmetric gait without prosilietic fitti ng. Range of motion in were preserved in ilie long posterior
tribute excessive leaning to either side. ilie lower limb and muscle strength in flap. The surgical scar was not adher-
:el and Proper foot rotation ts important her hand were within normal limits. ent, and ilie limb had a cylindrical
t in a both cosmetically and functionally. She had good upper limb strength shape. His right knee was stable in all

514 Section HI: The Lower Limb
planes of motion, 5/5 in strength, and Proper socket and alignment biome- 12. Soderberg GL: Kinesiology: Application
within normal limits for range. His chanics enable patients to function to to Pathological Motion. Baltimore, MD, l
general health was excellent. their fullest potential. A knowledge- Williams & Wilkins, 1986, p 208. 25. I-
The man was in vocational coun- able rehabilitation team can help pa- 13. Lauben thal KN, Smidt GL, S
seling with the desire to return to tients return to most or all of their Kettelkamp DB: A quantitative analy- tl
sis of knee motion during activities of a
work full time as a backhoe operator preamputation activities. In the ab-
daily living. Phys Ther 1972;52:34-42. 6
in a landscaping business. He had sence of other physical Limitations,
26.}
progressed to full-time ambulatory the prognosis for the transtibial am- 14. McCollough NC II!, Harris AR,
j;
use of his preparatory prosthesis and putee is good. Hampton FL: Below-knee amputation,
in Atlas of Limb Prosthetics: Surgical
a
was preparing to return to work. He s·
also wanted to return to high-impact and Prosthetic Principles. St. Louis, MO,
athletic activity and to train for run-
References CV Mosby, 198 1, pp 341-368.
A
b
ning events. His PTB prosthesis no l. Moore WS, Malone JM: Lower Extrem- 15. Edelstein J: Pre-prosthetic manage- (
longer fit comfortably because of ity Amputation. Philadelph ia, PA, WB men t of patients with lower or upper-
27. }
Saunders, 1989, pp 250-260. lim b amputation. Phys Med Rehabil
limb atrophy.
Clin N Am 1991;2:285-297.
s
2. Bruins M, Gee rtzen JH, Groothoff JW,
Prescription Recommendation Schoppen T: Vocational rein tegration 16. Wu Y, Keagy RD, Krick H J, Stratigos
after a lower limb amputation: A qual- JS, Betts HB: An innovative removable
A TSB socket to distribute pressure
itative study. Prosthet Ort/wt fnt 2003; rigid dressing technique for below-
evenly on the residual limb was rec-
27:4-10. the-knee ampu tation. J Bone Joint Surg
ommended. The cylind rical shape of
3. Schoppen T, Boonstra A, Groothoff Am 1979;61:724-729.
the residual limb is optimum for ac-
JW, van Sonderen E, Goeken LN, 17. Traub J: Immediate postsurgical pros-
commodating socket pressures. An Eisma WH: Factors related to success- theses past, present, and futu re.
elastomeric liner will absorb the ful job reintegration of people with a Orthop Prosthet Appl J 1967;148-152.
shock and shear of high-impact activ- lower limb amputation. Arch Phys Med
ity and reduce shear stress on the re- 18. Schon LC, Short KW, Soupiou 0, Noll
Rehabil 2001;82:1425-1431.
sidual limb skin. Suction suspension K, Rheinstein J: Benefits of early pros-
4. Girdha r A, M ital A, Kephart A, Young
thetic management of transtibial am-
with an expulsion valve and gel sleeve A: Design guidelines fo r accommodat-
putees: A prospective clinical study of
will eliminate pistoning of the pros- ing amputees in the workplace.
a prefabricated prosthesis. Foot Ankle
thesis on the residual limb and fur- J Ocwp Rehabil 2001;1 l :99-118. Int 2002;23:509-514.
ther decrease shear stress. A vertical 5. Fergason JR, Boone DA: Custom de-
19. Miller WC, Deathe AB, Speechley M,
shock- and torque-absorbing pylon sign in lower limb prosthetics fo r ath-
Koval J: The prevalence and risk fac-
will displace underloading conditions letic activity. Phys Med Rehabil Clin N
tors of falli ng and fear of falling
and absorb shock during high- Am 2000;11:681-699.
among lower extremity amputees.
dernand activity, as well as allow 6. Singh MA: Exe rcise to prevent and Arch Phys Med Rehabil 2002;82:
transverse rotation of the socket when treat functional disability. Clin Geriatr
1031- 1037.
the foot is on the ground. A dynamic- Med 2002; 18:431-462.
20. Fergason JF, Smith DG: Socket consid-
response foot will offer energy return 7. Van Heuvelen MJ, Kempen GI, Brou-
erations for the patient with a trans-
d uring high-demand activity. An en- wer WH, de Greef MH: Physical fit-
tibial amputation. Clin Orthop 1999;
doskeletal structure will remain align- ness re lated to disability in older per-
361 :80-83.
able and modular to allow changes in sons. Gerontology 2000;46:333-341.
21. Staats TB, Lundt J: The UCLA total
components or alignment as t he am- 8. Pinzur MS, Gottschalk F, Smith DG, et
surface bearing suction below knee
putee's activity level progresses. al: Functional outcome of below-knee
prosthesis. Clin Prosthet Orthot 1987;
amputation in peripheral vascular
11: 118-130.
insufficiency: A multicenter review.
Summary Clin Orthop 1993;286:247-249. 22. Pearson JR, Holmgren G, March L,
9. Smith DG, Fergason JR: Transtibial Oberg K: Pressures in critical regions
Given the many prosthetic choices of the below knee patella tendon bear-
amp utations. Clin Orthop 1999;361:
available to transtibial amputees, a 108-115. ing prosthesis. Bull Prosthet Res 1973;
thorough, objective evaluation and 10:53-76.
10. Yarkony GM: Aging skin, pressure ul-
detailed discussions about the pa- cerations, and spinal cord injury, in 23. Goh JC, Lee PV, Chong SY: Stump/
tient's functional level are vital. Some Whiteneck GG, Charlifue SW, Gerhart socket pressure profiles of the pressure
of the factors affecting component se- KA, et al (eds): Aging With Spinal Cord cast prosthetic socket. Clin Biomech
lection include time since the ampu- Injury. New York, NY, Demos, 1993, 2003;18:237-238.
tation; skin condition; medical condi- pp 39-52. 24. Sanders JE, Greve JM, Mitchell SB,
tions affecting sight, balance, and 11. Perry J; Gait Analysis: Normal and Zachar iah SG: Material properties of
strength; and home environment, in- Pathological Function. New York, NY, commonJy-used interface materials
cluding the social support structure. McGraw-Hill, l992, pp 61-69. and their static coefficients of friction

...... ,..
~ion with skin and socks. J Rehabil Res Dev problems of the residual limb and sili- 30. Powers CM, Torburn L, Perry J,
v!D, 1998;35: 161 - 163. cone liners in transtibial am putees Ayyappa £: Influence of prosthetic
25. Heim M, Wershavski M, Zwas ST, et al: wearing the total surface beari ng foot design on sound limb loading in
Silicone suspension of external pros- socket. Arch Phys Med Rehabil 200 l ;82: adults with unilateral below-knee am-
theses: A new era in artificial limb us- 1286- 1290. putations. Arch Phys Med Rehabil 1994;
1ly-
:s of age. J Bone Joint Surg Br 1997;79: 28. Pinzur MS, Cox W, Kaiser J, Morris T, 75:825-829.
638-640. Patwardhan A, Vrbos L: The effect of 31. Sanders JE, Daly CH, Burgess EM:
42.
26. Narita H, Yokogushi K, Shii S, Kak- p rosthetic alignment on relative lim b Interface shear stresses duri ng ambu-
izawa M, Nosaka T: Suspension effect loading in persons with trans-tibial lation with a below-knee prosthetic
ttion,
and dyna mic evaluation of the total amp utation: A preliminary report. limb. J Reha bi/ Res Dev 1992;29: 1-8.
ii
surface bearing transtibial prosthesis: J Rehabil Res Dev I 995;32:373-377.
MO, 32. Fridman A, Ona I, lsakov £: The influ-
A comparison with the patellar tendon 29. Pitkin MR: Mechanical outcomes of a
ence of prosthetic foot alignment on
bearing transtibial prosthesis. Prosthet rolling-joint prosthetic foot and its
e- trans-ti bial gait. Prosthet Orthot i nt
Orthot Int 1997;21 :175- 178. performance in the dorsiflexion phase 2003;27:17-22.
,ii
>per- 27. Hach isuka K, Nakamu ra T, Oh mine S,
Shitama H, Shi nkoda K: Hygiene
o f transtibiaJ am putee gait. J Prostlzet
Orthot 1995;7:114- 123.
50S
,vable
w-
tSurg
pros-
152.
>,Noll
· pros-
.I am-
1dy of
A.nkle
~yM,
<fac-
,es.
consid-
:rans-
1999;
total
knee
: 1987;
ch L,
regions
on bear-
:s 1973;
ump/
: pressure
omech
:USB,
:rties of
1terials
f fr iction

ln1
In 1
tion
the
valu
spee
amo
tech
lary
lies.
van,
dud
and
flap,
flap:
flap:
Cllta
dinf
cart:
of
pre,,
fort:
weif
1':
tion
mur
of tl
far
tom
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segr
obje
the
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kne,
thes
bull
clot
Knee Disarticulation: Surgical
Management
Michael S. Pinzur, MD
Int roduction
In 1940, Rogers 1 described the evolu- during swing phase. Thus, despite the weight-bearing residual limb with the
tion of knee disarticulation. Before ease and safety of the surgery and the appearance of a very long transfemo-
the use of surgical anesthesia, the advantage of end-weight bearing ral limb. The first successful pros-
value of knee disarticulation was the along normal proprioceptive path- thetic method to reduce the inequal-
speed of the surgery and the limited ways, knee disarticulation had not ity between the thigh and shank
amount of associated bleeding, as this gained wide acceptance in North portions was introduced by Lyquist7
technique does not violate the medul- America. in 1976. The Orthopaedic Hospital of
lary cavity or transect any muscle bel- The reduction of femoral length Copenhagen prosthesis featured a
lies. Surgical techniques have used a and distal bulkiness while retaining four-bar-linkage polycentric knee that
variety of surgical flap designs, in- end-weight bearing was first ad- allowed the shank to fold under the
cluding a circular flap, equal anterior dressed in the 1800s by Stokes,2 who socket when the patient was seated.
and posterior flaps, a long anterior advocated the use of a supracondylar This design reduced the distal protru-
flap, a long posterior flap, and sagittal amputation with fixation of the sion of the thigh portion. Improved
flaps. As originally described, these cartilage-denuded patella to the distal versions of this knee are still used.
flaps consisted only of skin and sub- end of the femoral metaphysis. 3 The Wagner8 was the first to use the
cutaneous tissue with no other pad- main problems of this procedure were gastrocnemius muscle bellies to pro-
ding between the skin and articular pain from failure of bony union and vide a cushion beneath the femoral
cartilage of the distal femur. The lack inability to achieve functional end- condyles to enhance end-bearing
of additional cushioning, however, weight beaTing, probably because of comfort. This technique was success-
prevented some patients from com- the small area presented distally by fully combi11ed with sagittal flaps,
fortably using the distal femoral the patella. leading to a resurgence of interest in
weight-bearing surface. In 1966, Mazet and Hennessy4 re- knee disarticulation. In 1985, Klaes
A disadvantage of knee disarticula- duced distal bulkiness in the frontal and Eigler9 reported the use of a long
tion is that if the full length of the fe- plane by trimming the medial and lat- posterior myofasciocutaneous flap,
mm is retained, the mechanical axis eral condyles. Bulkiness was reduced
including the gastrocnemius muscle
of the prosthetic knee must be placed in the sagittal plane by trimming both
bellies. Excellent padding is provided,
far distal to the contralateral ana- condyles posteriorly and excising the
and the perforating vessels from mus-
tomic knee center, which makes the patella. In 1977, Bmgess5 addTessed
cle to skin are undisturbed. A com-
thigh segment too long and the shank the issue of excess length by removing
plete description in English was pro-
segment too short. Amputees often the distal 1.5 cm of the condyles. This
vided by Bowker and associates. 10
object to t11is appearance. In addition, procedure provides the prosthetist
the short shank can prevent a pros- with the ability to raise the knee joint
thetic foot from reaching the floor center by this amount. Burgess also Advantages of Knee
when the patient is seated. E:>..'ternal reduced the sagittal diameter by pa-
tellectomy.
Disarticulation
knee joints can be used to mitigate
these problems, but they add to distal In 1992, Bowker6 reported the use Current prosthetic technology takes
bulkiness and can damage overlying of a combination of the techniques of adva11tage of the weight-bearing
clothing witl1out providing control Mazet and Burgess that produces a properties of knee disarticulation.

posterior to the ground-reaction force men

Knee flexion angle = 10° I vector, thus acting to create an intrin- vela
sically stable knee joint during initial dist,
stance phase because a knee extension (4) f
Knee center moment is created 12' 13 (Figure 1). tran
T he physiologic cost of walking met
with a knee disarticuJation is midway reco
between those of transfemoral and ada1
transtibial amputation levels with re- kne<
Knee center spect to walking speed and oxygen ter ~
consumption per meter walked. 14- 17 tern
Transtibial amputees who are com- tion
munity ambulators increase the activ- env<
ity of the retained muscles to com- resi,
pensate for the lost muscles. 18 In J
contrast, household (limited) ambu- bon
lators have no increase in muscle re- for
cruitment during gait. 19 This obser- wei;
vation might explain the similarity of or ·
walking propulsion in sedentary pa- loac
tients to that of persons with trans- tiss1
tibial amputations or knee disartic- mu:
ulations. Composite data suggest act~
virtually no functional differences and
Figure 1 Whenever the ground-reaction force (weight-bearing line) falls posterior to
the knee center, an external knee flexion moment is created and the prosthetic knee during walking in transtibial ampu- thi.c
w ill f lex abruptly under load. If t he amputee steps onto the prosthesis with the knee tees who are marginally ambulatory to
slightly flexed, t he typical single-axis knee w ill be unstable, as illustrated on t he left. and in patients who underwent knee bre
Many polycentric knees have an effective knee center similar to that shown on the disarticulation. 12' 19 The enhanced sta- the.
right, resulting in an external knee extension moment during weight bearing even
bility of walking after knee disarticu- tho
when the knee is slightly f lexed. (Reproduced with permission from Pinzur MS: Gait
analysis in peripheral vascular insufficiency through-knee amputation. J Rehabil Res Dev lation, as well as the population of ade
1993;30:388-392.) unilateral transtibial amputees under- fun
going a second amputation, suggests am
an important role for knee disarticu- qm
Knee disarticulation allows direct Retention of all or a major portion lation . 12 site
load transfer to the residual limb with of the weight-bearing surface of the tra·
enhanced walking independence and distal femur allows distribution of the ma
less energy consumption compared load over a large surface area. 6·u The qu.
with transfemoral amputation. When impact of initial loading during Indications a 1
combined with certain polycentric stance phase of gait is dampened by Use After Trauma or in dis
(four-bar-linkage) prosthetic joints, the biomechanical properties of the Patients With Infection sev
knee disarticulation can offer en- metaphyseal bone and the gastroc- Forward propulsion during the termi- tee
hanced walking stability in the geriat- nemius-based end pad. nal stance phase of gait is accom· mt
ric population. In growi ng children, Walking stability is another key plished by knee extension against a tat
knee disarticulation provides a dura- benefit of knee disarticulation. In the stable foot and ankle. When foot sal- du
ble residual limb that avoids the po- intact limb, the vertical ground- vage is not possible because of trauma COJ
tential for appositional terminal bony reaction force vector along the hip- or infection, every effort should be dif
overgrowth that is often observed af- knee-ankle axis of the lower limb made to retain the forward propulsive
ter transosseous amputations. Surgi- passes posterior to the axis of the capacity of the knee joint and proxi·
cal techniques designed to maximize knee joint at initial contact (heel Ui
mal tibia. Transtibial amputation
function and the development of strike). This creates a knee flexion should be performed when the fol· Pc
polycentric knee joints with fluid moment that can cause the knee to lowing structures can be retained: n
swing-phase controls have established flex ("buckle") if not adequately (1) a serviceable knee joint with no cie
knee disarticulation as an important counteracted by the action of the more than a 20° loss of full extension; tis
component of a well-rounded ampu- quadriceps. Some polycentric knee (2) the proximal end of the tibia, in- ati
tation program. joint designs place the knee center cluding the patellar tendon attach- va

Ch apter 40: Knee D isarticulation: Surgical Management 519
cnent; (3) an adequate soft-tissue en- sue at the proposed level of amputa- Patients with poorly controlled
:ce
velope of mobile muscle to cover the tion can be determined preoperatively congestive heart failure or those on
.n-
distal end of the remaining tibia; and by noninvasive vascular testing. Intra- dialysis for end-stage renal disease of-
ial
(4) full-thickness skin in a1·eas of load operatively, viability of tissue can be ten have diurnal lower limb volume
on
transfer. If these criteria cannot be assessed by examining muscle color fluctuations that result in marl<ec!Jy
met or compensated for by creative and consistency, skin and muscle increased distal pressures on the trans-
.ng
,ay reconstructive surgery or prosthetic bleeding, and muscle contractiJity tibial residual limb. Thus, the pros-
adaptation such as a thigh corset and when stimulated by electrocautery. thetic socket does not fit intimately
nd
knee joints, these patients may be bet- Patients with amputations at the level throughout the day. Patients with ma-
re-
ter served by knee disarticulation. At- of the tibial tubercle with an intact jor volume fluctuations can do better
;en
1- 17 tempting to fit a traJ1Stibial amputa- patellar tendon insertion retain the with knee disarticulation and end
tion without an adequate soft-tissue functional independence of transtib- bearing rather than total surface bear-
rn-
envelope will often lead to repeated ial amputees. If sufficient vascularity ing. In these patients, the reduced
tiv-
residual limb ulceration and pain. is present for a knee disarticulation to requirement for intimate socket fit al-
,m-
A soft-tissue envelope covering the lows fabrication of a volume-
In heal, it is also likely that amputation
adaptable socket (Figure 2).
bu- bone of the residual limb is essential at a proximal trnnstibia] level will
Individuals who are morbidly
re- for comfortable prosthetic fitting and heal.
obese are always difficult to fit for a
,er- weight bearing after any amputation A minor knee flexion contracture
prosthesis because the adipose tissues
{ of or disarticulation. Pressure or shear often improves with prosthetic limb
tend to displace proximally in the
pa- loads are best accepted when the soft- fittu1g and walking, but when a con-
prosthetic socket under weight-
ms- tissue cover is composed of mobile tracture approaches 45°, the patient
bearing shear forces . This displace-
tic- muscle and full- thickness skin, which may not be able to use the
ment results i11 unacceptable tension
gest acts to both cushion direct pressure quadriceps-powered tibial lever arm.
in the distal soft tissues over the bone
1ces and dissipate shear forces. Split- These individuals may, therefore,
at the end of the residual limb. In
.pu- thickness skin grafts in areas subject achieve optimal functional indepen-
obese patients, end-bearing proce-
tory to pressure and/or shear will often dence after primary knee disarticula-
dures such as a Syme ankle disarticu-
:nee break down in adults, especially if tion. Hip flexion contracture causes lation or knee disarticulation may be
sta- these grafts are adheren t to bone. Al- the vertical ground-reaction force more beneficial in terms of reduced
icu- though a knee disarticulation with an vector at initial contact (heel strike) pain and soft-tissue injury compared
1 of adequate soft-tissue envelope will to align posteriorly to the anatomic with a transosseous amputation.
der- function far better than a tra nstibial knee center, leading to knee instability Dysvascular lll1ila teral transtibial
;ests amputation performed with an inade- and buckling with frequent falls. Plac- amputees who are marginal walkers
icu- quate soft-tissue envelope, the oppo- ing the patient in the prone position and require a contralateral amputa-
site has also been observed. Thus, the for several periods daily can often re- tion may benefit from knee disarticu-
trauma surgeon should know that it duce hip flexion contracture. Surgical lation instead of transtibial amputa-
may not be possible to create an ade- release is rarely necessary to correct tion, although this is controversial.
quately cush ioned end pad for either hip flexion contracture. These patients can take advantage of
a transtibial amputation or a Jknee Some patients with ambulatory the intrinsically stable polycentric
disarticulation in patients who have potential may benefit from knee dis- knee joint of a knee disa.rticulation
severe soft-tissue injury. These ampu- articulation rather than transtibial prosthesis during stance phase, and
rm1- tees will ultimately function better if a amputation, even though they meet retain the forward propulsion of the
:om- muscle-balanced u·ansfemoral ampu- other accepted criteria for transtibial knee JOlllt on the transtibial
1st a tation is performed to elin1inate or reamputation. One group consists of side. 12, 20 •21 The functional effects of
t sal- duce the discouraging cy:cle of dis- patients who, after a cerebral vascular this approach on activities other than
luma comfort, recurrent ulceration, and accident, have a spastic lower hmb standing and level walking, such as
d be difficulties in prosthetic fitting. with a significant knee flexion con- stair clin1bing, walking on inclines,
tlsive tracture and an w1salvageable foot. If and rising from a chair or the floor,
·roxi- these patients retain reasonable vol- have not been investigated.
Use in the Dysvascular lll1tary control of the hip, they can be
ation
: fol- Patient successfully fitted with and use a
T he presence of viable tissue suffi- prosthesis after a knee disarticulation. Use in Children
ined:
:h no cient to provide an adequate soft- In contrast, retaining a knee with Knee disarticulation in children has
1sion; tissue envelope is the first consider- spastic flexors will only lead to an in- generally been confined to the tTeat-
a, ination in patients who have peripheral creasing knee flexion contractw-e and ment of those with congenital defi-
:tach- vascular disease. The viability of tis- the inability to fit a prosthesis. ciencies, malignant tumors, trauma, or

Figure 2 A, This patient with diabetes mellitus weighs more than 350 lb and would be difficult to fit with a conventional knee disar-
ticulation socket. Using a volume-adaptable prosthetic socket (B and C), he was able to walk independently and comfortably bear
much of his weight on the end of his residua l limb.
following transfemoraJ amputation.

Knee flexion contracture in the non- Figu
ambulatory transtibial amputee often and
leads to pressme ulcers on the distal
residual limb (Figure 3). nal
The residual limb of the transfem- bon
oral amputee provides a small plat- that
form for sitting in a chair and a lever con
arm that is inefficient for use in trans- ove:
fers (Figure 4). A minimal sitting area
sidt
decreases trunk stability and limits ta!
B the ability of the bilateral transfemo-
afte
ral amputee to safely lean forward to
Figure 3 A, This transtibial amputee developed a knee flexion contracture because of trai
perform tasks with tbe upper limbs,
muscle imbalance when using a wheelchair. B, Constant residual limb pressure on the the:
patient's bedding led to the development of a large terminal ulcer, which could be re-
such as picking up a dropped object.
ma
solved only by conversion to knee disarticulation. (Reproduced with permission from Knee disarticulation, in contrast, pro-
tio1
Pinzur MS, Smith DG, Daluga DJ, Osterman H: Selection of patients for through-the· vides a stable platform for sitting and
knee amputation. J Bone Joint Surg Am 1988;70:746-750.)
mi;
a long, powerful, muscle-stabilized
pre
femoral lever arm to assist in posi-
tioning and transfers (Figure 5). In sio:
infection. Femoral length in growing Use in Nonambulatory jor
addition, knee disarticulation has the
children is maintained by preserving Patients benefits of minimizing surgical blood
the growth potential of the distal fem- dis
Knee disarticulation is most com- loss and maintaining the cartilage
oral physis. This procedme also avoids am
monly indicated for nonambulatory barrier, which potentially reduces the
the risk of appositional bony over- tell
individuals, such as those who are risk of infection in this population of
growth inherent with pediatric tran- bed-bound in a skilled nursing facility. compromised patients. 10 • 11 SUI~
sosseous amputation.22 The residual ln general, these patients meet most bU:
femur tends to grow at a slower rate criteria for t:ranstibial amputation but ual
than the contralateraJ femm. Such do not have the real potential for pros- Surgical Techniques be
growth allows the prosthetic knee thetic ambulation. 11 •25 · 27 In addition, Bone sid
joint center to eventually approach the muscle imbalances can cause these pa- The distal terminal femur is well fac
level of the normal contralateral knee tients to develop a knee flexion con- suited to accommodate loading be- pl)
and maintains the advantages of end- tracture after transtibial amputation cause of its large surface area. The po
weight bearing. 23•24 or a hip flexion-abduction contracture metaphyseal bone of the distal termi- by

Chapter 40: Knee Disarticulation: Surgical Management 521
Figure 5 Knee disarticulation provides a

stable platform for sitting and a strong
lever arm to assist in transfers. (Courtesy
of JH Bowker, MD)
lisar-
bear
tion.
1on- Figure 4 Transfemoral amputation provides a small platform fo r sitting in a chair (A)
and an inefficient lever arm t o assist transfer from the chair (B).
>ften
listal
nal femur is less stiff than cortical moved 1.5 cm from the condyles dis-'
fem- bone and thus dissipates the impact tally to keep the knee centers level but
plat- that occurs at initial distal loading. In d id not narrow them. Based on a se-
lever contrast, loading must be distributed ries of osteoplasties by Mazet and .
:ans- over the entire surface area of the re- Burgess, Bowker6 showed that the
area sidual limb and relieved from the dis- weight-bearing characteristics of the
imits tal end for the indirect load transfer distal femm are retained by shorten-
~mo- after transosseous (transtibial or ing it by 2 cm and retaining the ante-
rd to rior cruciate ligament for quadriceps
transfemoral) amputations; both of
mbs, tenodesis. Shortening of the femur
these criteria must be met for an inti- Figure 6 Sagittal flaps used in Wagner's
Dject. was perhaps more relevant before the version of the kn ee disarticulati on. The
mate prosthetic fit. Knee disarticula-
pro- development of the polycentric four- apex of t he skin f lap is midway between
tion allows end bearing and minj-
~ and bar-linkage prosthetic knee joint. Al- the inf erior pole of t he patella and t he
mizes the necessity for an intimate t ibial tuberosity. Th e length of each flap
ilized
prosthetic fit, which makes suspen- though reduction of the distal femw· is one half the diameter of t he limb at
posi-
sion of the prosthetic socket the ma- in1proves cosmesis, this may impair the level of the knee j oint . (Reproduced
i). In with permission from Pinzur MS, Smith
jor requirement. suspension and rotational control.
LS the DG, Daluga DJ, Osterman H: Selection of
Rogerst elected to retain the entire
Dlood Soft Tissues patients for through-the-knee amputa-
tilage distal femoral weight-bearing surface tion. J Bone Joint Surg Am 1988;70:746-
and recommended fusion of the pa- Each of the aforementioned bony con- 750.)
~s the
tella to the anterior femur to enhance figurations has its proponents. Knee
.o n of
suspension. This procedure created a disarticulation, however, was not
bulky but reasonably functional resid- widely used, partly because of its lim- tissue. Wagner's8 major contribution
ual limb. Reduction osteoplasty can ited abi.lity to accept the load of weight was the introduction of an end-
~s be used to decrease the bulk of the re- bearing. Earlier flap designs had a hjgh bearing gastrocnemius cushion for
sidua] limb. The distal articular sur- rate of wound failure and poor ability amputations at this level. This refine-
well face can be retained, however, by sim- to act as the interface between the ment, combined with the develop-
.g be- ply trimming the medial, lateral, and prosthetic socket and the residual limb ment of the polycentric prosthetic
.. The posterior protuberances as advocated because the soft-tissue envelope con- knee joint, brought knee disarticula-
termi- by Mazet and Hennessy.4 Burgess5 resisted only of skin and subcutaneous tion to the forefront as a valuable com-

able or heavy absorbable sutures. The II

B
distal pole of the patella should not ex- a pr<
tend beyond the distal femur. The the 1
cushioned end pad is created by sutur- the
ing the posterior gastrocnemius fascia crea:
to the knee joint reti.naculum without theti
tension or redundant muscle. To en- can
sure that the muscle flap is centered, avai
the first suture should attach the mus-
Figure 7 A, The posterior myofasciocutaneous flap is virtually identical to that used in cle flap to the center of the patellar
performing a transtibial amputation. This illustration of the medial aspect of the knee
tendon. The skin is closed with sutures
Im
shows the outline of the flap. B, This illustration shows the pendent posterior flap still
attached distally. The plane has been opened between the soleus muscle anteriorly and or staples.8 ' 11 Po
the gastrocnemius muscle posteriorly. (Adapted with permission from Bowker JH, San Mi
Giovanni TP, Pinzur MS: North American experience with knee disarticulation with use Posterior
of a posterior myofasciocutaneous flap: Healing rate and functional results in seventy- Myofasciocutaneous Flap Ari
seven patients. J Bone Joint Surg Am 2000;82:7577-7574.) pref
of Klaes and Eigler
swe
The posterior myofasciocutaneous soil
flap has been adapted by .Klaes and pos
Eigler9 for knee clisarticulation. 10 This ted
flap is familiar to amputation sur- a ri:
geons as it is virtually identical to that lim
used for a midlength transtibial am- atee
putation. By avoiding dissection be- On,
tween the muscle and skin, this proce- wal
dure lessens the potential for skin flap
necrosis caused by division of the per-
forating vessels. A transverse anterior
s,
incision is made at the level of the Kn,
knee extending to the midlateral line mo
on each side. Longituclinal incisions a ~
extend from each end of the trans- lev,
verse incision to the distal limit of the abl
gastrocnemius bellies, where they are for
joined with a transverse cut. The exc
Figure 8 Bilateral knee disarticulations in a bed-bound nursing home patient using the
posterior myofasciocutaneous f lap of Klaes and Eigler. The left disarticulation is mature
plane between the gastrocnemius bel- po·
and the right one is recent. (Courtesy of JH Bowker, MD.) lies and the soleus is found meclially fer
and bluntly dissected to the lateral ar€
side (Figure 7). The gastrocnemius- pre
ponent of a functionally oriented am- The flaps are raised in the interval be- soleus conjoined tendon is then cli- pal
putation program. tween the skin and deeper structures. vided transversely to free the flap clis- dr<
The patellar tendon is detached tally. The rest of the procedure is OV•
Sagittal Flap Technique of (skived) from the tibial tuberosity. The similar to the Wagner technique. In pu
Wagner knee joint capsule is incised circum- addition to suturing the quadriceps
Wagner8 used sagittal flaps to mini- ferentially at the level of the knee joint, tendon to the cruciates, the mectial
mize the length of the soft-tissue flaps leaving the menisci with the tibia. The and lateral hamstring tendons should R
in dysvascular patients (Figure 6). The cruciate ligaments are detached from be sewn to the capsule to preserve l
use of a tourniquet is optional. The the tibia. The gastrocnemius bellies are their function as hip extensors. In a
skin flaps begin at a point midway be- separated from the soleus. The poste- similar manner, the iliotibial band
tween the inferior pole of the patella rior tibial and common peroneal should be sutured to enhance abduc- 2
and the tibial tuberosity and end at an nerves are gently drawn clistally and tor function and hip extension by the
opposite point in the popliteal fossa. clivided. The popliteal vessels are dou- gluteus maximus. The resulting an-
The length of both medial and lateral bly ligated. The quadriceps muscle is 3
teroclistal transverse scar lies directly
flaps is half the diameter of the limb at stabilized at a normal length by sutur- over the gastrocnemius muscle bel-
the level of the knee joint plus 1 cm, ing the patellar tendon to the residual lies, which cushion the scar from
which can be trimmed if redundant. cruciate ligaments with nonabsorb- tratuna (Figure 8).

Chapter 4 0: Knee D is artic ulation: Surgical M anagement 523
[he In patients who are expected to use Louis, MO, CV Mosby, 1949, tion. J Bone Joint Surg Am 1976;58:
a prosthesis, the posterior condyles of pp 222-226. 42-46.
ex-
the femur can be removed flush with 4. Mazet R Jr, Hennessy CA: Knee disar- 16. Waters RL: The energy expenditure of
The
the posterior femoral cortex to in- ticulation: A new technique and a new amputee gait, in Bowker JH, Michael
tur-
knee-joint mechanism. J Bone Joint JW (eds): Atlas of Limb Prosthetics:
.scia crease terminal flexion of the p ros-
Surg Am 1966;48: 126-139. Surgica~ Prosthetic, and Rehabilitation
lOUt thetic knee. Any of these techniques
5. Burgess EM: Disarticulation of the Principles, ed 2. Rosemont, IL, Ameri-
en- can be modified , dependi n g on the can Academy of Orthopaedic Sur-
knee: A modified technique. Arch Surg
:red, availability of viable soft tiss ue . geons, 2002, pp 381-387. (Originally
1977;112: 1250-1255.
nus- published by Mosby-Year Book, 1992)
6. Bowker JI-I: Abstract: reduction osteo-
ellar Immediate plasty of the distal femur to enhance 17. Pinzur MS, Gold J, Schwartz D, Gross
tures prosthetic fitting i11 knee disarticula- N: Energy demands for walking in
Postoperative tion, in Proceedings of the Seventh dysvascular amputees as related to the
M anagement World Congress ofthe International So- level of amputation. Orthopedics 1992;
ciety for Prosthetics and Orthotics. Chi- 15:1033-1037.
A rigid plaster or fiberglass dressing is 18. Breakey J: Gait of unilateral below-
p cago, IL, International Society for
preferable to a soft dressing to control knee amputees. Orthot Prosthet 1976;
Prosthetics and Ortbotics, 1992, p 267.
swelling and protect the wound from 30:17-24.
7. Lyquist E: The OHC knee-
1eous soiling or tra u ma during the early 19. Pinzur MS, Asselmeier M, Smith D:
disarticulation prosthesis. Orthot
s and postoperative period. The most simple Prosthet l 976;30:27-28. Dynam ic electromyography in active
) This techn ique is the addition of a pylon to and limited walking below-knee am-
8. Wagner FW Jr: Management of the
l sur- a rigid dressi n g . Fitting of a prosthetic putees. Orthopedics 1991;14:535-538.
diabetic-neurotrophic foot: Part II. A
.o that limb and weight bearing can be injti- classification and treatment program 20. Pinzur MS: Gait analysis in peripheral
Ll am- ated as soon as the wou nd is secure. for diabetic, neuropathic, and dysvas- vascular insufficiency through-knee
m be- Once t he patient becomes stable in cular foot problems. Instr Course Leet amputation. J Rehabil Res Dev 1993;30:
proce- walking, a knee joint can be added. l 979;28:143-165. 388-392.
in flap 9. Klaes W, Eigler FW: Eine neue Technik 21. Pinzur MS, Cox W, Ka iser J, Morris T,
der transgen icularen Amputation. Patwardhan A, Vrbos L: The effect of
1e per-
nterior
Summary Chirurg 1985;56:735-740. prosthetic alignment on relative limb
loading in persons with trans-tibial
of the Knee disarticulation is most com- 10. Bowker JH, San Giovanni TP, Pinzur
an1putation: A preliminary report.
ral line mon ly indicated for patients in whom MS: North American experience with
J Rehabil Res Dev 1995;32:373-377.
,cisions a surgical wow1d at the transtibial knee disarticulation with use of a pos-
ter ior myofasciocutaneous flap: Heal- 22. Epps CH Jr, Schneider PL: Treatment
trans- level will heal, but who will not be of hemimelias of the lower extremi ty:
ing rate and functional results in
t of the able to walk. The residual limb Long-term results. J Bone Joint Surg
seventy-seven patients. J Bone Joint
hey are formed by this procedure provides an Am 1989;71:273-277.
Surg Am 2000;82: 1571-1574.
1t. The excellent platform for sitting and a 23. Loder RT, Herring JA: Disarticulation
1 l. Pinzur MS, Smith DJ, Daluga DJ, Os-
.ius bel- powerful lever arm to assist in trans- terman H : Selection of patients for of the knee in children: A functional
nedially fers and bed mob ility. In patients who through-the-knee amputation. f Bone assessment. J Bone Joint Surg Am 1987;
: lateral are ab le to walk, knee disar ticulation Joint Surg Am 1988;70:746-750. 69:1155-1160.
nemius- provides a durable residual limo ca- 12. Pinzur MS, Smith D, Tornow D, 24. Thomas B, Schopler S, Wood W, Op-
:hen di- pable of direct load transfer. In chil- Meade K, Patwardhan A: Gait analysis penheim WL: The knee in arthrogry-
flap dis- dren, it avoids the poten tial for bony of dysvascular below-knee and con- posis. Clin Orthop 1985;194:87-92.
edu re is overgrowth often observed after am- tralateral through-knee bilateral am- 25. Pinzur MS: New concepts in lower-
Lique. In putations at transosseous levels. putees: A preliminary report. limb amputation and prosthetic man-
Orthopedics 1993;16:875-879. agement. Instr Course Leet 1990;39:
Ladriceps
13. Greene MP: Four bar linkage knee 361-366.
e medial
lS should
References analysis. Orthot Prosthet 1983;37: 26. Pinzur MS: Current concepts: Ampu-
1. Rogers SP: Amputation at the knee 15-24. tation surgery in peripheral vascular
preserve
joint. J Bone Joint Surg 1940;22: 14. Fisher SV, Gullickson G Jr: Energy cost disease. Instr Course Leet 1997;46:
ors. In a 501-509.
973-979. of ambulation in health and disability:
,ial band
2. Stokes W: On supracondylar amputa- A literature review. Arch Phys Med 27. Pinzur MS, Bowker JH, Smith DG:
:e abduc- Gottschalk f: Amputation Su rgery in
tion of the thigh. Proc Roy Med Chir Rehabil 1978;59:124-133.
on by the Peripheral Vascular Disease. Instr
Soc London 1870;6:289. 15. Waters RL, Perry J, Antollelli D, Hislop
llting an- Course Leet 1999;48:687-692.
3. Slocum DB: The end-bearing amp uta- H: Energy cost of walking of ampu-
:s directly tees: The influence of level of amputa-
tions, in An Atlas ofAmputations. St
uscle bel-
;car frorn

Knee Disarticulation: Prosthetic
Management
Rebekah Russ, CPO, LPO
Introduction
Knee disarticulation offers many ad- tlletic knees designed specifically for tlle condyles, and some improvement
vantages over transfemoral amputa- knee disarticulations are commer- of rotational control of the prosthesis.
tion, but the procedure is still some- cially available, compared with well In the absence of end-bearing capac-
what uncommon in North America. over one hundred for higher levels. ity, deweighting of the distal femur is
The exception is in the pediatric pop- Despite the disadvantages associ- necessary, which requires extra space
ulation, in which knee disarticulation ated with knee disarticulations, the and padding as well as a proximal
is preferred over procedw·es at higher procedure bas significant benefits. Af- socket design similar to those used for
levels because it retains both epiphy- ter comparing patient satisfaction and transfemoral levels that emphasizes
ses and avoids bony overgrowth. For functional outcome of knee disarticu- support through the ischial tuberosity
any amputee, the fact that knee disar- lation patients in Sweden, Hagberg and proximal soft tissues.
ticulation allows end bearing-the and associates 2 concluded that knee Patient evaluation should include
ability of the intact femoral condyles, disarticulation "should always be con- an inventory of the multiple benefits
articular surfaces, and overlying soft sidered as the primary alternative to that knee disarticulation can provide.
tissues to tolerate the patient's super- AK [above-knee] amputation when a When it is available, distal weight bear-
inctunbent weight- is a significant BK [below-knee] amputation is not ing transfers forces in a more physio-
advantage over amputation at the feasible." logically normal fashion tluough the
transfemoral level, which requires femur to the pelvis and trWlk. As
that pelvic structures provide most of demonstrated by the ability of most
the support. Through-knee surgery is
Patient Evaluation people without amputations to kneel
also less traumatic because no bones When the knee joint is disarticulated, comfortably, the pressure-tolerant ar-
or muscles are cut, so strength, mus- the distal end of the femur, which is ticular surface, soft tissues, and skin
cle tone, and balance are generally ex- the largest horizontal load-bearing around the knee are well adapted to
cellent. The retained femoral condyles surface in the lower limb, is retained. weight bearing. Many persons with a
also enhance the patient's rotational In most cases, this diminishes or ne- knee disarticulation can kneel with
control and ability to suspend the gates the need for weight bearing the prosthesis off. This is a significant
prosthesis. through the iscbial tuberosity. This advantage for amputees with bilateral
Disadvantages of knee disarticula- benefit should not be assumed, how- knee djsarticulations, many of whom
tion are mostly associated with cos- ever. Hip joint pathology, femoral ab- can ambulate for short distances
mesis, challenging socket design, and normality, compromised distal sensa- without prostheses. To maximize tl1is
more limited options for prosthetic tion or circulation, tenuous skin potential, a second pair of short, pro-
knees. t The often bulbous distal end coverage, painful neuromas, patient tective sockets is often indicated in
requires prosthetists to use socket de- preference, or other challenges may addition to full-length prostlleses for
signs ,vith more visible openings and limit or rule out the patient's ability such patients. In addition, the con-
straps or a bulky appearance. Because to bear weight successfully through tours of tl1e femoral condyles and pa-
the full length of tl1e femur is re- tlle end of the femur. In such cases, tella (if present) enhance tlle patient's
tained, the prosthetist may find it dif- the only advantages of knee disarticu- rotational control of the prosthesis
ficult or impossible to match the knee lation may be avoidance of bony over- and often provide an excellent means
centers. Fewer than ten types of pros- growth (in children), suspension over of suspending the device. Also, the

526 Section, III: The Lower Limb
be acceptable to some patients. Fi- funct

nally, although rare, a hip flexion con- pie,
tracture combined with the long knee.
length of the thigh and the need to will
position the knee well behind it will mise:
create a poor cosmetic result. cerni
H istory and physical examination
details that should be reviewed for
any level of amputation are pertinent St e
for the knee disarticulation level as Imm
well. Before recommending a pros- (!PC
thetic design and treatment plan, the thesi
health care team should consider the disai
following important questions specif- Ieng,
ically related to this level: (1) Are the with
femora l condyles intact or shaved? ings,
How wide are they, and how bulbous tach
--
Figure 1 A polycentric knee disarticula-
is the distal end of the limb? The size
and shape of the distal femur relative
to the thigh will determine socket and
in f
than
but
t ion knee was used for this fitting, but suspension options. Surgically re- rem
the long femoral length, combined w ith duced condyles may be less tolerant of ral ,
a distal pad, attachment bracket , plastic,
and hardware, resu lted in a slightly
pressure. The overall dimension of the
longer thigh section on the prosthetic the reduced distal femur may not al- pad,
side. (Courtesy of Texas Scottish Rite Hos- low suspension of the prosthesis. an'
pital.) (2) How long is the femur? If the af- corr.
fected femur is the same length as the the
opposite femur, either a prosthetic will
long and powerful lever arm of the fe- knee designed specifically for patients give
mur is retained. One obvious advan- who have had a knee disarticulation are,
tage for children is that the distal or outside joints will offer the most sidt
femoral epiphysis is retained, preserv- cosmetic result. In children, an appro- pre:
ing 90% of femoral growth. Because Figure 2 Photograph of a "traditional" priately timed epiphysiodesis may be pro
no bones are cut, terminal osseous molded leather socket with outside indicated so that more knee options ma'
hinges. Modern versions may use more
overgrowth, which is common among are available by adulthood. (3) Does or i
hygienic t hermoplastic materials and Vel-
children with transdiaphyseal ampu- cro closures rather than laces. Outside the patient have normal hip function,
tations, is avoided. Proprioception is hinges enable the knee centers to match, especially on the prostl1etic side? The gin
better because the Limb is longer; this but bulkiness is unavoidable. (Repro- hip must be capable of tolerating bui
duced with permission from Edwards JW forces translated from the distal end En<
is an advantage for both children and (ed): Orthopaedic Appliances Atlas, Ann
adults. through the femur to the pelvis. Oth- ual
Arbor; Ml, American Academy of Ortho-
Even though these advantages gen- paedic Surgeons, 1960, Vol 2, p 225.) erwise, a transfemoral amputation the
erally translate into functional bene- socket style must be used. (4) Are the afo
muscles of the thigh in good balance?
fits and patient satisfaction, knee dis-
To match knee centers, prosthetists Hip flexion contractmes ase more an
articulations have some obvious
traditionally used external, single-axis cosmetically obvious in longer limbs. in~
drawbacks.2 When femoral lengths joints (Figure 2) that were inherently Also, control of the prosthesis and the be
are equal, the prosthetist cannot bulky. Most offered no friction or degree of knee stability required are rec
match the knee centers exactly (Fig- fluid control, so they were often noisy determined by hip strength. (5) Can siv
ure 1). Padd ing for the distal femm and wore out quickly in active pa- the patient tolerate pressure distally? ha·
(which is generally recommended), tients. The development of modern Has the scar healed well, and is the lirr
socket thickness, attachment brackets, polycentric knees has improved cos- limb sensate? If distal pressure is not he:
and the prosthetic knee itself all add mesis, function, and durability for tolerated, more proximal structures
additional length. Unless the patient this level. will have to provide support. (6) Are wi
is willing to accept a much longer Another disadvantage is that the other limbs involved? What other op
prosthetic "thigh," options for knee wide femoral condyles and resulting limitations or challenges does the pa- co
mechanisms are limited. bulky appearance at the knee may not tient face? (7) What are the patient's on

Chapter 41: Knee Disarticulation: Prosthetic Management 527
Pi- functional goals? A runner, for exam- tibial plateau before the amputation, tuaJ effort; (5) no strnps, laces, or sus-
on- ple, may require a fluid-controlled the prosthetist will need to pay partic- penders; (6) minimal extra width or
ong knee. A long limb and bulbous end ular attention to the distal anatomy of length compared with the normal
l to will require some cosmetic compro- the residual limb. Firm, supportive anatomy of the thigh and · knee;
wi!J mises. (8) What are the patient's con- distal pads are generally preferred be- (7) ability to be fitted with every type
cerns regarding cosmesis? cause they enable comfortable weight of knee joint designed for knee disar-
tion bearing and still protect tissues against ticulations, including the possibility
for trauma. Pads that are too thick may of knee locking or swing-phase con-
1ent
St aging of Care add bulk or lower the knee center. The trol; (8) no special clothing adapta-
1 as Immediate postoperative prostheses entire lower surface of the femur may tions required, and no extra wear
ros- (IPOPs) or early postoperative pros- support the patient's weight, but the caused by the prosthesis should be
the theses can be applied following knee patella generally requires protection noticed; (9) easy to clean for effective
the disarticulation, but additional chal- from external pressures. For tl1is rea- residual limb hygiene; (10) light, but
~cif- lenges will be encountered compared son, some surgeons remove it. 3 Fi- able to withstand the patient's activi-
the with other procedures. Rigid dress- nally, when the prosthesis is being fab- ty; (11) adjustable for residual limb
ved? ings, with or without a pylon at- ricated, care is required to minimize shape and volume changes; (12) capa-
)OUS tached, may actually be easier to keep the distance between the distal end of ble of being fabricated by standard
size in place after a knee disarticulation the socket and the attachment to the manufacturing techniques, requiring
1tive than after a transfemoral amputation, knee (Figure 1). no extra skill from the prosthetist
and but tl1e cast may be more difficult to who is familiar with normal anatomy
re- remove for wound access. The femo- and cw-rent manufacturing tech-
1t of ral condyles can be used to suspend niques; and finally, ( 13) .the socket
1 of the prosthesis, but they should be well
Socket Design, should cost no more than conven-
t al- padded, and the cast should include Suspension, and tional prostheses. 5
.esis. an auxiliary waist belt for safety and Rarely will all of these lofty goals
Interfaces be realized in one design. However,
e af- comfort. The wound closure is near
; the the distal femur, where the patient
Socket Design multiple socket variations intended to
1etic will bear weight, so care shouldl be Socket design for the patient who has meet the unique needs of a patient
ients given to padding and protecting this had a knee disarticulation is often who has had a knee disarticulation
1tion area. As with all amputations, the re- dictated by tlle degree to which distal are available.
nost sidual limb is sensitive to external weight bearing is tolerated and the Traditional anterior lacing sockets
pre- pressure in the first weeks after the size of the femoral condyles relative to are rarely used in the United States
y be procedure. If the patella is retained, it the circumference of tlle thigh. Some today, but the design does have ad-
[ions may be especially sensitive to pressure of the most common approaches are vantages (Figure 2). This type of
Does or shear forces.3 described here, but multiple creative socket is still commonly used in many
tion, Ideally, physical therapy should be- variations exist that are as unique as countries where it is preferred be-
The gin before prosthetic fitting to help the patients who wear tllem and the cause of material availability or famil-
ating build strength and range of motion. prosthetists who design tl1em. iarity with the technique. Whether
end End bearing should be initiated grnd- Botta and Baumgartner5 began made of flexible resins, thermoplas-
Oth- ually and cautiously through physical their treatise on socket design by stat- tics, or leather, this socket has a
ation therapy within the first 4 to 6 weeks ing, "The bulbous shape of the resid- lengthwise anterior opening that al-
e the after surgery. 3 ual limb and its full end-bearing qual- lows the passage of the wide femoral
mce? If the patient does not begin with ity requires a socket wh ich has very condyles. The prosthesis is then fas-
more an IPOP or rigid dressing, soft dress- little resemblance to above-knee sock- tened around the residual limb using
robs. ings, elastic wraps, or shrinkers may ets." They go on to describe the ideal laces, Velcro straps, or some other
d the be used immediately after surgery to requirements for a knee disarticula- form of closure. The molded flexible
:1 are reduce swelli and pain. Compres- tion socket: ( 1) total surface contact socket fits snugly over the bulbous
Can sive dressings, wr ps, or shrinkers also in both the sitting and the upright distal femur, thus suspending the
tally? have the benefit f desensitizing the position; (2) total end-bearing quality prosthesis.6 Because the system is
s the limb to outside pr ssure, which may (in normal anatomy the femoral contoured directly against the atro-
s not help when fittin 1e prothesis.4 condyles transmit fu!J weight to the phied thigh, it is rarely overly bulky in
tures Once the li nb is ready for fitting tibial plateau and vice versa); (3) no appearance. However, some patients
) Are with a more de lflitive socket, multiple ischial seat and, therefore, free motion have objected to poor durability or
other options are ~vailable. If the femoral of the hip joint; ( 4) easy doffing and hygiene problems related to the
e pa- condyles are to transmit full weight donning witl1 the patient sitting, re- leather, and others did not like the ap-
ient's onto ilie prosthesis, as they did on the quiring no extra physical or intellec- pearance of the anterior opening and

Su
part I
the ~
tion.
dyles
suspe
atric
is P·
cienc
Figure 4 A soft distal pad and liner can derd c
both provide suspension over the femoral
By strap adeq
condyles and enhance comfort and pro-
By residual tection of the resid ual limb. Once sis. 11
limb pens:
donned, the liner enables the limb to
pass like a compressible cylinder through wais1
the socket. Compression of the liner ing E
between the socket walls, against the
Figure 3 Illustration shows how a remov- ca tee
limb, and over the femora l condyles
able plate or "window " allows the bul- keeps the prosthesis in place. (Repro- ing,
bous condyles to pass through the socket; duced with permission from Baumgartner hom
they are secured with a Velcro strap. This RF: Knee disarticulation versus above- Alte1
method is particularly advantageous for knee amputation. Prosthet Orthot Int
mature, atrophied limbs with wide and flarii
1979;3: 15-19.)
prominent femora l condyles. It may not Figure 5 The liner can be split to enable tiorn,
work well when the condyles are buried t he femora l condyles to pass through it (Fig1
in soft tissue, such as in obese or muscu- so t hat children, geriatric patients, or bi-
lateral amputees can don it easily. Many
pros
lar patients. (Reproduced with permission
from Hughes 1: Biomechanics of the variations of such suspension pads are posi
An internal pad or liner can also be
through-knee prosthesis. Prosthet Orthot available. Materials include closed-cell be u
used to secure the prosthesis over the polyethylene foams, foam and leather,
Int 1983;7:96-99.) cord
femoral condyles (Figures 4 and 5). silicon, and urethane. (Reproduced with
susp
Botta and Baumgartner5 advocated permission from Botta P, Baumgartner R:
Socket design and manufacturing tech- spac
visible laces or straps. Originally, this the use of an inner foam liner, either
nique for through-knee stumps. Prosthet tivel
design was used with external m etal long or short, to suspend the knee
Orthot Int 1983;7:100-103.) fied
hinges. When combined with modern disarticulation prosthesis and to facil-
dist,
knees, this socket design may still itate donning and doffing. The short
me,c
benefit some patients. version extends up the thigh only to built into ilie socket but is not part of
the
ilie point at which fue thigh circum- · ilie suspension device. Prosthetic
pati
ference is equal to the largest circum- socks are worn against the residual
latic
Suspension and Interfaces ference of the bulbous distal femur. limb wifu an additional layer that is
The liner includes a distal pad. Layers less
A removable "window," which can be pulled on once the pad is positioned. tio11
fastened back in place, allows the of foam are added to ilie liner and Because this method does not require
shaped until a cylindrical form of sus1
wearer to pass tl1e femoral condyles the use of a complete liner, no addi-
consistent circwnference with tapered
through the socket comfortably (Fig- tional bulk is added around the bul-
proximal edges is produced. A fuU
ure 3). Traditionally, the opening is
liner extending to the proximal socket
bous distal end. Cc
located medially, where it is less visi- If the femoral condyles are not
brim is another alternative. With ei- Th€
ble. When the plate is repositioned overly prominent, they can be pushed sod
ilier type of liner, a split can be made
and fastened tightly, the prosfuesis t hrough an expru1dable inner elastic
in ilie foam for easier donning. Usu- usu
suspends over the condyles. A down- wall or flexible socket (Figure 6).
ally, the patient dons the liner over a kne
side of this method is iliat it adds ma- prosthetic sock and then steps into Originally, this type of suspension ten
terial to the thigh section and thus the prosfuesis. A thin sock worn over consisted of a stretchy silicone "blad- tier
may have a less desirable appearance. fue insert may reduce friction, mak- der" wifu a void between it and the def
Also, the design generally works best ing it easier for the patient to attach outer socket to allow passage of the per
for a well-atrophied limb of stable and remove the prosthesis. femur. This design, however, is quite ora
volume wiili prominent femoral A similar type of suspension in- difficult to make, and postfabrication the
condyles. 7 If the distal femur is not volves the use of a split cylindrical adjustments to the socket are often tic€
bulky enough for suspension, some suspension pad that the patient slips not possible.8 Similar designs are now qui
oilier form of socket may be pref- over the lower femur, converting it to made wiili flexible thermoplastic in- cer
erable. a cylindrical shape. A distal pad is ner sockets or gel liners. km

Chapter 41: Knee DisarticuJation: Prosthetic Management 529
Suspension is often an inherent

part of socket design, particularly for
the patient with a knee disarticula-
tion. Self-suspension over the con-
dyles is generally the most desirable
suspension for these patients. In pedi-
atric patients, if a knee disarticulation
is performed for congenital d efi-
ciency, the distal femur may be un-
derdeveloped and unable to provide
adequate suspension of the prosthe-
sis. In such patients, transfemoral sus-
pension methods such as a variety of
waist belts or suction, Silesian, lock-
ing gel, or silicon w1ers may be indi-
cated. Suction can be obtained by us-
ing a flexible irrner socket and valve,
housed within a rigid outer frame.
Alternatively, if there is little or no
flaring to the distal femur, a tradi-
1able tional suction socket may be used
gh it (Figure 7). When the femur on the
,r bi-
prosthetic side is shorter than the op-
lllany
; are posite side, a gel locking liner might
cl-cell be used. Lanyard systems, which use a
1th er, cord rather than a pin and lock to
with suspend the prosthesis, conserve
,er R:
tech-
space for the prosthetic knee. A rela-
,sthet tively new option resembles a modi-
fied ski boot buckle that eliminates
distaJ attachments through a locking Figure 6 This young man underwent a Figure 7 This socket uses both the elas-
mechanism mounted on the side of knee disarticulation following a trau· ticity of a flexible socket and a suction
rrtof matic injury. The flexible socket stretches valve to suspend the limb. A slight cir-
the gel liner and outer socket.9 For cumferential void between the outer
hetic through the frame cutouts just enough
patients with bilateral knee disarticu- to enable the femora l condyles to enter socket and the inner flexible socket en-
idual lations, conserving space distally is ables the femora l condyles to slip into
the socket. Voluntary muscle contraction
1at is less critical; thus there are more op- also holds the prosthesis on more tightly. the prosthesis. A distal pad, not visible, is
med. tions for prosthetic knees and types of Although the prosthetic knee center is located inside the socket, below the f lex-
quire lower than the opposite side, the result is ible insert. The proximal brim is designed
suspensions. cosmetically acceptable. (Courtesy of for some weight bearing on the ischial
addi- tuberosity. Although this is not usually
Texas Scottish Rite Hospital.)
bul- necessary, it can help spread forces over a
Components larger surface area. (Courtesy of Texas
: not Scottish Rite Hospital.)
The distance between the end of the
1shed socket and the anatomk knee center is
:lastic usually a key determinru1t of which knee disarticulation: ( 1) outside tl1e opposite knee joirit. Distally,
e 6). knee is most appropriate. There are of- joints, (2) knee mechanisms tradition- they attach to a prosthetic shin, usu-
nsion ten many options for pediatric pa- ally used for transfemoral amputees, ally of the exoskeletal type. One or
blad- tients and those with congenital l imb and (3) knee disarticulation polycen- two designs are suitable for active pa-
d the deficiencies when an epiphysiodesis is tric knees. tients. They include a yoke and
>f the performed or there is ru1 existing fem- linkage system that enables a hydrau-
quite oral length discrepancy. However, Outside Joints lic or pneumatic cylinder to be placed
:ation these situations are rare in adult prac- Outside joints were used more fre- inside the shin. Outside joints allow
often tice. Options for prosthetic knees are quently in the past. They consist of the prosthetist to match the knee cen-
e now quite limited if approximating knee heavy-d uty single-axis joints, often ter more closely, but they often have
ic in- centers is a goal. Three general types of including ball bearings, that are an uncosmetic appearance because of
knees are appropriate for the typical mounted on the socket at the level of the added width at the knee. 10

stance-phase stability, minimal knee

protrusion when sitting, and
acceleration-deceleration qualities in-
herent to a moving center of rotation.
A few of these multiaxis knees also in-
clude hydraulic or pneumatic units,
thus addressing the control needs of
active patients who vary their walking
speed (Figure 9). Michael 11 has elo-
quently described how a polycentric
knee functions: "The point at which a
polycentric knee prosthesis appears to
be bending at a given moment is re-
ferred to as its instant center of rota-
tion. Many polycentric knee prosthe-
ses have an instant center of rotation
that is located in a very proximal and
posterior location compared with the
anatomic knee center. The more pos-
terior the instant center of rotation is
located with reference to the ground
Figure 8 The knee-disarticulation four- figure 9 Cutaway view of a knee disartic- reaction force, the greater the knee
bar-linkage is designed to fold up be- ulation shin and outside j oints connected extension moment developed in early
neath the thigh segment when f lexed to to a hydraulic unit through a special yoke.
90°, thus reducing the anterior protru- The hydraulic cylinder provides variable- stance and the more stable the pros-
sion of the knee when sitting. Only a few cadence swing-phase control. The outside thes.is becomes."
of the polycentric, or four-ba r, knees on joints enable t he prosthetist to match the Foot and ankle components for
the market are designed to provide this knee center to t hat of the opposite side. this level should be selected by the
advantage specifically for pat ients who Theoretically, the hydraulic swing-phase FigL
same criteria used for transfemoral
have had a knee disarticulation. (Repro- unit should also minimize noise and en- the
duced with permission from Michael JW hance the durability of t he external
prostheses. Because of the tendency of
botI
Component selection criteria: Lower limb hinges. (Reproduced with permission flexible keel feet to reduce stress on sod
disarticulation. Clin Prosthet Orthot 7988; from Michael JW: Component selection the relatively fragile knee units often fror
12:99-108.) criteria: Lower limb disarticulation. Clin used with this level, they may be pref- side
Prosthet Orthot 1988;72:99-708.) erable over more rigid designs such as reac
al) •
the solid ankle-cushion heel (SACH)
Transfemoral Knee cau
the new class of mkroprocessor- foot. 1 fro,
Mechanisms thrc
controlled knees. These are discussed
Another category includes most of Int
the knee mechanisms trad itionally
in detail in other chapters in this text. Biomechanics
used for transfemoral amputees. Knee Disarticulation In general, the biomechanical chal-
When used in conjunction with a lenges of fitting and aligning the pa-
Polycentric Knees twc
knee disarticulation, nearly all of tient with a knee disarticulation are
these will result in a lower prosthetic The third class includes knee disartic- kn,
similar to those encountered with
knee center as well as a thigh that ulation polycentric knees (Figme 8). for
transfemoral amputation. Yet there
appears longer than the opposite side. These are distinguished from other are some notable differences. Many of by
Nevertheless, these can be appropriate polycentric or multiaxis knees be- these, such as intact thigh muscula- (Fi
for bilateral amputees in whom the cause they are designed specifically ture, distal weight-bearing capacity, thi
affected femur is shorter than the for patients with knee disai-ticula- rotational control, suspension over kn
opposite side or for patients who are tions, minimizing the space required the condyles, and an extended lever no
willing to accept a lower knee center to attach them below a socket. They arm, have already been discussed. Be- SU"
to gain the benefit of a certain knee. also fold under the prosthetic socket cause of these advantages, inruviduals pr,
This category includes single-axis, during flexion, further mm1mmng who have had a knee disarticulation in
constant-friction knees; stance- the appearance of an overly long can generally be expected to have an be
control knees; manual lock knees; thigh section. As with most poly- equal or greater degree of control be
polycentric knees not designed specif- centric knees, these knees provide over their prostheses than will pa- Ill:
ically for knee disarticulations; some benefits over single-axis knees. tients with amputations at higher pr
hydraulic-controlled knees; and The advantages include enhanced levels. 7 te1

Chapter 41: Knee Disarticulation: Prosthetic Management 531
nee
md
in-
ion.
10-
lits,
s of
M
cing Socket motion
elo- relative to limb
ttric
ch a
:s to L
Socket motion
; re- relative to limb
ota-
the-
tion Force
A B
and
I the
Figure 11 Center of rotation in a knee disarticulation socket and in a transfemoral
pos-
socket. A, In a low-profile knee disarticulation socket, because of weight bearing on the
m is end of the femu r and the exclusion of the ischial tuberosity from the socket, the center
>Und of rotation of the socket about the limb is located distally. During midstance, the socket
knee tends to rotate about this point and must be stabilized by counterpressure along the
early proximal aspect of the thigh. 8, In a transfemoral socket, because of pelvic (ischial) bear-
,ros-
; for
t p
ing, the center of rotation of the socket about the limb is located proximally, at and
around the ischium. As a result, the socket tends to rotate distally about the limb during
midstance. Medial containment of the ischium may provide counterpressure to resist
and decrease socket motion. (Reproduced with permission from Hughes 1: Biomechanics
r the of the through-knee prosthesis. Prosthet Orthot Int 1983;7:96-99.)
,oral Figure 10 During single-limb support on
the prosthesis, the body mass applies
cyof both vertical and rotary forces to the tion around the end of the residual ticulation. Initially, he was fitted with
,s on socket. The pelvis tends to drop away
limb in the coronal plane. The result- a suspension pad and socks with a
often from the prosthesis, toward the opposite
side. W = center of gravity, P = ground- ant pressures will be concentrated at waist belt for auxiliary suspension.
pref-
reaction force, M (medial) and L (later- the distal lateral femur and the proxi- The suspension worked well, and he
.ch as
al) = force couple opposing the moment mal medial thigh. If this is not con- continued to use this method until he
\CH) caused by P. (Reproduced with permission sidered when the socket modifica- was 17 years of age. Initially, the fe-
from Hughes 1: Biomechanics of the
tions are completed, the patient may murs were of equal length, but in the
through-knee prosthesis. Prosthet Orthot
Int 1983;7:96-99.) have a resultant adductor roll at the first year postoperatively, the physi-
proximal medial brim. With a trans- cian and family decided an epiphysi-
femoral amputation, however, the dis- odesis should be performed to stop
chal-
One biomechanical distinction be- tal end of the residual limb can toler- the growth of the left femur so that
.e pa-
n are
tween transfemoral amputation and ate only minimal pressure. Axial the difference in the length of the fe-
knee disarticulation is related to the loading in the transfemoral socket is murs would be approximately 6 cm.
with
there forces generated on the residual limb concentrated on the ischial tuberosity This difference would allow for more
myof by the socket during stance phase and proximal musculature (Figure options for prosthetic components
scula- (Figure 10). A simplified discussion of 11 ). Thus the proximal posterior and and would maintain the advantages of
,acity, these forces is presented here. The proximal medial brim, and not the the knee disarticulation. After the
over knee disarticulation prosthesis does distal end, become the center of rota- growth was arrested, the prosthetist
lever not generally rely on ischial or gluteal tion of the transfemoral socket. 7 was able to place a hydraulic unit on
d. Be- support as does the transfemoral the prosthesis and closely match the
prosthesis. Thus the center of rotation knee centers. The patient was inter-
iduals
in a knee disarticulation socket will
Case Study ested in skateboarding and was quite
1lation
:1ve an be located at the distal end; that is, An 18-year-old man incurred thermal successful at this activity for a few
ontrol because the residual limb is end bear- burns when he was 11 years old. years. He later went on to be an active
11 pa- ing dming single-limb support on the Compartment syndrome developed member of a local band. At 18 years
higher prosthetic side, the socket will at- in the lower left leg and the patient of age, the patient transitioned to a
tempt to rotate in an external di1·ec- w1derwent a subsequent knee disar- prosthetic design with a flexible inner

and rigid outer socket (Figure 7). He overgrowth, and enables end-weight 5. Botta P, Baumgartner R: Socket design
could tolerate end-weight bearing but bearing. Among adults, knee disartic- and manufactming technique for
wore a socket that allowed some ulation is generally considered to be through-kJlee stumps. Prost/iet Orthot
weight to be supported by the ischiaJ functionally superior to amputation Int 1983;7:100-103.
tuberosity. The inner socket is flexible at transfemoral levels, but only if full 6. Gardner H: Basic steps in the fabrica-
enough for the residual limb to push distal weight bearing is achieved. 7 tion of the through-knee socket, in
through and get distal contact. The Many prosthetic sockets and knees Report Workshop on Knee Disarticula-
outer socket provides a void proximaJ have been designed to take advantage tion Prosthetics of the Subcommittee on
of the supracondylar suspension ca- Design and Development. San Fran-
to the femoral condyles so they can be
cisco, CA, National Research Council,
pushed through easily. Suction and pacity, long lever arm, and distal load
Subcommittee on Design and Devel-
the contours of the femoral condyles tolerance associated with knee disar- opment, 1970.
provide suspension. The patient has ticulation.
7. Hughes J: Biomechanics of the
also changed to a four-bar knee disar-
through -knee prosthesis. Prosthet
ticulation knee on this prosthesis and
a dynamic-response foot. The new
References Orthot Int 1983;7:96-99.
design of the prosthesis has allowed l. Michael J: Component selection crite- 8. McCollough NC III, Shea JD, Warren
ria: Lower limb clisarticuJations. Clin WD, Sarmiento A: The dysvascular
the patient to be highly functional.
Prosthet Orthop 1988; 12:99- 108. amputee: Surgery and rehabilitation.
Int
2. Hagberg E, Berlin OK, Renstrom P: Curr Prob[ Surg 1971: l-67. Tran
Summary Function after tl1rough -knee com- 9. www.coyotedandm.com. Accessed on forrr:
pared with below-knee and above- July 16, 2004.
Knee disarticulation offers many the I
knee amputation. Prosthet Orthot Int
functional advantages and a few cos- 10. Oberg K: Knee mechanisms for in p
1992;16: 168-173.
metic disadvantages compared with through-knee prostheses. Prosthet dise,
3. Baumgartner R: Failures in through-
amputations at more proximal trans- Orthot Int I 983;7:107-112. level
knee amputation. Prosthet Orthot Int
femoral levels. This procedure is pre- 1983;7:116-118. 11. Michael JW: Modern prosthetic knee
Mos
ferred over transfemoral amputation mechanisms. Clin Orthop at le:
4. www.aarogya.com/specialties/
for children because it preserves both 1999;361:39-47. for I
physiothernpy/amputationpost.asp.
femoral epiphyses, eliminates osseous Accessed on July 16, 2004. spee
tion:
amp
lack
be f
ofte1
ers
pros
als
prol
mal
or"'
ciat<
und
tion
cam
and
use.
1'
mac
Cati,
cam
mer
gic.a
ade,
the
tho·
or
One

hot Transfemoral Amputation:
ca- Surgical Management
'a- Frank Gottschal~ MD, FRCSEd, FCS(SA)
on
JCil,
·el-
Ten
Lr
on.
Introduction
Transfemoral amputations are per- primary wound healing, but biome- two-legged stance, this axis measures
I on formed much less frequently than in chanical principles of lower limb 3° from vertical and the femoral shaft
the past, but they are often necessary function do not need to be sacrificed axis measures 9° from vertical. There-
in patients with very severe vascular to achieve this. fore, the normal anatomic alignment
disease a nd diabetes, in whom a lower When performing a transfemoral of the femur is in adduction, which
level amputation is unlikely to heaJ. amputation, it is important to main-
Most transfemoral amputees expend tain a residual limb with as much
~ee length as possible. The longer the re-
at least 65% more energy than normal
for level wall<lng at a regular walking sidual limb, the easier it is to suspend
speed. 1' 2 Underlying medical condi- a prosthesis as well as to align it. The
tions often contribute to this; for ex- functional ability of the patient is also
ample, many dysvascular amputees improved with a longer residual limb.
lack the physical reserve required to In some circumstances, the pre- "'x
be functional walkers and therefore vailing local pathology may require a .,<.<
u
often will be limited household walk- more proximal transfemoral amputa- z< .,x
ers or unable to use a transfemoral tion. In these cases, a small portion of :,: <
prosthesis.3 However, even individu- the femur at the trochanteric level ~

als with no concomitant medical should be left when possible. This al-
TRANS·
problems are unable to achieve nor- lows for enhanced prosthetic fitting \/ERSE
AXIS T
mal gait in terms of velocity, cadence, by providing additional contouring.
or walking economy. Waters and asso- The longest possible residua] limb
ciates4 found that patients who had should be created because the longer
undergone a transfemoral amputa- limb provides a longer lever arm that
tion as a consequence of nonvascular can help with transfers and sitting
causes also had limited ambulation balance. It can also reduce the poten-
and problems related to prosthetic tial for bone erosion through the soft
use. tissues.
Many improvements have been
made in prosthetic design and fabri-
cation, but even the best prosthesis
Biomechanics
Figure 1 Mechanical and anatomic axes
cannot provide a reasonable replace- Normal Alignment of normal lower limbs. H = hip; K = knee;
ment for the limb following poor sur- The normal anatomic and mechanical A = ankle; S = shaft axis; T = transverse
gical technique that results in an in- alignment of the lower limb has been axis; V = vertical axis. (Reproduced with
adequate residual limb. Too often well defined 5 • 7 (Figure 1). The me- permission from Gottschalk F, Kourosh
S, Stills M, McClellan 8, Roberts J:
the procedure is performed without chanical axis of the lower limb runs Does socket configuration influence the
thought for biomechanical principles from the center of the femoral head position of the femur in above-knee am-
or preservation of muscle function. through the center of the knee to the putation? J Prosthet Orthot 1990;2:
One of the major goals of surgery is midpoint of the ankle. In normal 94-102.)

residual femur in a more adducted the h

CM
position by adj usting the socket femo
0 shape8 or using the ischium as a ful- phy O
crum.9 However, a radiologic study of des t
5 transfemoral amputees revealed that in the
the position of the residual femur the il
10
could not be controlled by the socket the l
shape or alignment. 10 Positioning the range
15
soft tissues in adduction does not in- The,
fluence the position of the femur. muse
20 Of the three adductor muscles- lengtJ
the adductor magnus, the add uctor sidua
25 longus, and the adductor brevis-the muse
adductor magnus has a moment arm wasn
30 with the best mechanical advan- to av<
10 11
tage. • Figure 3 shows the direc- hip 1
35 tions of the components of force of tract.
the adductor muscles normal to the con tr
40 lines joining t he points of attachment posec
Figure 2 Radiograph showing abducted of the muscles. The adductor magnus and {
residual femur resulting from inadequate 45 is three to four times larger in cross- teus 1
muscle stabilization. (Reproduced with sectional area and volume than the whid
permission from Gottschalk F, Kourosh S,
adductor Jongus and brevis com- tract;
Stills M, McClellan B, Roberts J: Does
socket configuration influence the posi- bined. Transsection of the adductor unatt
tion of the femur in above-knee amputa- magnus at the time of amputation mech
tion? J Prosthet Orthot 1990;2:94-102.) thus leads to a major Joss of muscle Tb
Figure 3 Moment arms of the three ad-
ductor muscles. Loss of the distal attach- cross-sectional area, a reduction in <leper
ment of the adductor magnus resu lts in a the effective moment arm, and a loss In nc
allows the hip stabilizers (gluteus me- 70% loss of adductor strength. AB = ad- of up to 70% of the adductor pull. 11 ducto
djus and minimus) and abductors ductor brevis; AL = adductor longus;
This combination results in overall chore
(gluteus meruus and tensor fasciae la- AM = adductor magnus. (Reproduced
with permission from Gottschalk F, weakness of the adductor force of the putat:
tae) to function normally and reduce
Kourosh S, Stills M, McClellan B, Roberts J: thigh and subsequent abduction of muse.
the lateral motion of the center of
Does socket configuration influence the the residual femur. In addition, loss of the dt
mass of the body, thus producing a position of the femur in above-knee am- the extensor portion of the adductor tractl
smoother and more energy-efficien t putation? J Prosthet Orthot 1990;2:94-
magnus leads to a decrease in hlp ex- Theg
gait. 102.)
tension power and a greater likeli- atrop
In most transfemoral amputees, tees.
hood of a flexfon contracture.
mechanical and anatomic alignment residual femur in an abducted and strin~
is rusrupted because the residual fe- flexed position. This abducted posi- Muscle Atrophy Chan:
mur is no longer in the natw·al ana- tion leads to an increase in side lurch Thiele and associates 12 showed that a ampu
tomic alignment with the tibia, and and higher energy consumption when reduction in m uscle mass at amputa- ume
the femoral shaft axis is in abduction the amputee walks. tion, combined with inadequate me- Addit
compared with the contralateral limb. Because the original insertions of chanic~ fixation of muscles and atro- bone
This is because in a conventional the adductor muscles are lost, the ef- phy of the remaining musculature, crease
transfemoral amputation the major fective moment arm of these muscles was the major factor responsible for lary c
portion of the adductor muscle inser- becomes shorter. Thus, the remaining the decrease in muscle strength de-
tion is lost, especially the adductor smaller mass of adductor muscle tected in transfemoraJ amputees. The Elec
magnus, which has an insertion on would have to generate a larger force decrease in strength of the flexor, ex- Electr
the meruorustal third of the femur. to hold the femur in its normal posi- tensor, abductor, and adductor mus- norm
Dw·ing surgery, once this attach- tion. The muscles are unable to gener- cles of the hip was most noticeable, ducto
ment is lost, the femur drifts into abate this force, so an abducted position which correlated with inadequate and e:
duction because of the relatively un- results (Figure 2). muscle stabilization. 13 SWing
opposed action of the abductor Prosthetists have recognized that Jaegers and associates 14 ' 15 docu- trom}
system. The surgeon then sutures the residual femoral abduction compro- mented muscle atrophy following associ
residual adductors and the other mises function. Newer prosthetic transfemoral amputation. Three- limbs
muscles around the femur with the socket designs have tried to hold the d imensional MRI reconstructions of tnaintt

Chapter 42: Transfemoral Amputation: Surgical Management 535
:ted the hip muscles of 12 healthy trans-

cket femoral amputees were studied. Atro-
ful- phy of 40% to 60% was noted in mus-
y of cles that had been sectioned, whereas
that in the intact muscles, which included
mur the iliopsoas, the gluteus medius, and
,cket the gluteus minimus, the atrophy
: the ranged from 0% to 30% (Figure 4) .
tin- The amount of atrophy of the intact
muscles was related to residual limb
.es- length, with less atrophy in longer re-
1ctor sidual limbs. Despite the presence of
-the muscle atrophy, fatty degeneration
arm was not noted. The authors attempted
lvan- to avoid abduction contracture of the
lirec- hip by not reattaching the iliotibial
ce of tract. This strategy led to hip flexion
o the contractures because of (l) the unop-
ment posed action of the iliopsoas muscle Figure 4 Three-dimensional MRI recon-
and (2) the large insertion of the glu- struction of a residual limb fol lowing
i.gnus
transfemoral amputation. Note the atro- Figure 5 Xerogram of the thigh of a pa-
:ross- teus maxirnus into the gluteal fascia,
phy of the detached muscles (arrows). tient following transfemoral amputation
n the which continues into the iliotibial (Reproduced with permission from Mur- shows the abducted residual f emur and
com- tract; thus, leaving the iliotibial tract doch G, Wilson 8 (eds): Amputation: Sur- unattached medial soft tissue.
luctor unattached weakens the extensor gical Practice and Patient Management.
tation mechanism. Oxford, England, Butterworth Heineman,
7996, pp 7 7 7-7 78.) abductors by allowing the adductor
nuscle The atrophy of the adductors also
on in depended on the level of amputation. magnus to maintain close to normal
a loss In none of the patients was the ad- tivity as a normal limb but for a longer muscle power and a better mechanical
pull. l l ductor magnus adequately rean- time period. The activity of sectioned advantage for holding tl1e femur in
overall chored. The more proximal the am- muscles depended on whether they the normal anatomic position. A re-
of the putation, the greater the amount of had been reanchored and the level of sid ual limb with dynamically bal-
ion of muscle atrophy, and the more likely amputation. Muscles that were rean- anced function allows the amputee to
loss of the development of an abduction con- chored correctly rema.ined functional function at a more normal level and
ductor tracture and atrophy of the gl utei. in locomotion, especially in a distal use a prosthesis with greater ease.
Clip ex- The gluteus maximus was noted to be transfemoral amputation. The authors Several authors 19-22 recommend
likeli- atrophied in all transfemoral ampu- noted that alterations in muscle activ- transecting the muscles through the
tees. Lack of fixation of the ham- ity during walking were likely related muscle belly at a length equivalent to
strings resulted in up to 70% atrophy. to the altered morphology of once- half the diameter of the thigh at the
Changes in muscle morphology after biarticular hip muscles, the passive el- level of amputation. Muscle stabiliza-
l that a amputation are due to changes in vol- ements of the prosthesis, and the tion has also been advocated as a
mputa- ume and geometry (size and mass). changed gait pattern of the amputee. means of controlling the femur, but in
i.te me- Additional findings included reduced The degree to which the gait was actuality this is infrequently achieved
1d atro· bone density, cortical atrophy, and in- asymmetric was related to residual because the remaining muscle mass
ulature, creased volume of the femoral medul- limb lengtl1. The greater the atrophy will have retracted at the time of
ible for lary cavity. 14 of the hip stabi lizing muscles, the transection (Figure 5) . Reestablishing
gth de- greater the lateral bending of the the normal muscle tension, as recom-
ees. The Electromyographic Activity trunk to the prosthetic side. 18 mended in standard textbooks, then
:xor, ex· Electromyographic studies dming becomes more difficult. The authors
or mus- normal gait show activity of the ad- Surgical Approaches attempted muscle stabilization either
ticeable, ductor magnus at both the begiruning The goal of surgery in a transfemoral by myoplasty over the end of the fe-
1dequate and end of stance phase and into early amputation should be the creation of mur or by myodesis to the femur just
swing phase. 16 • 17 A separate elec- a dynamically balanced residual limb proximal to the end of the bone. My-
5 docu· tromyographic study by Jaegers and with good motor control a11d sensa- oplasty, in which the agonist and an-
ollowing associates 15 of transfemoral residual tion. Preservation of the adductor tagonist groups of muscles are su-
Tbree- limbs showed that the intact muscles magnus helps maintain the muscle tu red to each other over the bone end,
:tions of maintained the same sequence of ac- balance between the adductors and does not restore normal muscle ten-

sion, nor does it allow for adequate ful vascular bypass surgery improves additional debridement if necessary.
muscle control of the femur. The re- limb survival in patients with critical On occasion, split-thickness skin
sidual femur moves in the muscle en- ischemia, failure of the procedure grafts may be used on muscle to help
velope, producing pain and occasion- has resulted in more transfemoral preserve length. Revision surgery may
ally penetrating the soft-tissue amputations and residual limb com- be necessary and may require second-
envelope. Frequently a brnsa develops plications. Infectious gangrene re- ary skin expansion. Fractures of the
at the end of the cut femur. The loss of quiring amputation is most common femm should be stabilized by appro-
muscle tension leads to some loss of in patients with diabetes mellitus. Pa- priate means rather than amputating
control and reduced muscle strength tients with vascular disease associated through a proximal fracture site. The
in the residual limb. The soft-tissue with diabetes tend to be an average of orientation of skin flaps is not critical,
envelope around the distal end of the 10 years younger at the time of but closw·e must be without tension.
residual limb is unstable and may amputation than those patients with
compromise prosthetic fitting. Instead purely vascular problems. 25 Patients Infection
of myoplasty, a muscle-preserving with purely vascular disease are more Amputation for severe soft-tissue in-
technique is preferred whereby the likely to require transfemoral ampu- fection or osteomyelitis should be
distal insertions of the muscles are de- tation than are patients with diabetes done as a two-stage procedure at the
tached from their bony insertion and mellitus. 26 minimum, with antibiotic coverage.
reattached to the residual femur un-
der normal muscle tension. Once the
myodesis has been done, any redun-
Trauma
Most patients who require a trans-
In some situations, the placement
of antibiotic-impregnated methyl-
methacrylate beads or absorbable
--
dant tissue can be excised. femoral amputation as a result of antibiotic-impregnated substances is
trauma are younger than patients useful for controlling local infection. 12
requiring amputation because of dis- All in fected tissue must be excised be-
Indications for ease.27 Usually, the indication for am- fore definitive closrne.
Transfemoral putation is a combination of soft-
tissue, vascular, neurologic, and bone Tumor
Amputation damage so severe as to preclude satis- With tumors, the level of amputation
Vascular Disease factory limb salvage or subsequent often is determined by the type, size,
Vascular disease, including vascular function. Foreign material may be and location of the tumor. While ob-
disease associated with diabetes, is the embedded in the bone and soft tis- serving the principles of t umor eradi-
most common cause for transfemoral sues, requiring meticulous and at cation, as long a residual limb as pos-
amputation in developed countries. times repeated debridement. sible should be preserved so that
maximum function can be main- Figur
Most patients who require a trans- Injlll'ies from land mine blasts
bone
femoral amputation for vascular dis- and other high-velocity penetrating tained and restored. tatio
ease have widespread systemic mani- wounds cause extensive tissue damage
festations of the disease, which has because of energy transfer to tl1e tis-
several implications. The disease may sues. Bullet wounds treated more
Technique is de
compromise the patients' postopera- than 24 hours after injury are forn Proper positioning of the patient on flap
tive rehabilitation. Their physical re- times more likely to requi re a trans- the operating table facil itates the sur- flap.
serve is often insufficient to allow use femoral amputation than a transtibial gery. The patient should be supine how,
of a prosthesis. Acute ischemia of the arnputation.28 Any delay in treatment with the buttock on the side of the leg will
lower limb may result from thrombo- increases the risk of a more proxin1al to be amputated elevated on folded res id
sis or embolism, and it may be diffi- amputation because of increased in- sheets or blankets to allow for hip ex- skin
cult to determine which of the two fection and greater soft-tissue dam- tension and adduction during the post,
conditions is the cause of the is- age. Depending on the severity of the procedure. flap
chemia. Although embolism is the initial injury, early intervention could A tourniquet is general ly not used post,
more likely diagnosis in older pa- minimize the risk of amputation or for most transfemoral amputations be t,
tients,23 both systemic and local permit a lower level of amputation. for vascular disease, but one may be subc
causes must be considered. Chronic Maximum length should be reused for traumatic amputations. avoi<
ischemia necessitating amputation tained, but it is also important to have When used, the sterile tourniquet cial
usually involves gangrene of the foot a good soft-tissue envelope and avoid should be placed as high on the thigh skin
as a consequence of severe atheroscle- a spl it-thickness skin graft to bone. In as possible and released before setting this
rosis. Van Niekerk and associates 24 these cases, at least a two-stage proce- muscle tensions. Skin flaps should be end
have noted the association of failed dure is mandatory, leaving the marked before the skin incision (Fig- lead
bypass surgery with more proximal wounds open at the initial stage to ure 6). A long medial flap in the sag- Ano1
level amputations. Although success- avoid wound infection and allow for ittaJ plane is recommended.29 The flap flaps

ary.
5kin
ilelp
may
md-
. the
pro-
1ting
The
ti cal,
ion.
.e in-
d be
It the
~rage.
Figure 7 The adductor t endon is isolated before detachment from the adductor t uber-
:ment cle. The quadriceps tendon has been cut proximal to the patella. (Courtesy of John
ethyl- Bowker, MD.)
:bable
ces is
:ction. tension at wound closme because of tor tubercle by sharp dissection and
ed be- inadequate flap length. The sku1 flaps reflected medially to expose the femo-
should be made longer than may be ral shaft. It may be necessary to de-
ini6ally thought necessary to avoid tach 2 to 3 cm of the adductor mag-
having to shorten the bone more than nus from the linea aspera to incre~se
1tation otherwise necessary because insuffi- its mobility. The smaller m_uscles, in-
e, size, cient skin is available for closure. cluding the sartorius and gracilis, ·and
ile ob- After the medial skin flap is cre- the more posterior group of muscles
. eradi- ated, the adductor magnus tendon at- should be transected approximately 2
as pos- tachment to the adductor tubercle of to 2.5 cm longer than the proposed
o that the femur is identified30 (Figure 7). bone cut to facilitate their inclusion
Figure 6 Proposed skin flaps and level of The tendon is detached by sharp dis- and anchorage. The biceps femoris is
main-
bone section before transf emoral ampu-
tation.
section, marked with a suture, and re- transected at the level of the bone cut.
flected proximally, exposing Hunter's The femur is exposed just above the
canal. The femoral artery and vein are condylar level and transected approx-
is developed as a myofasciocutaneous identified. imately 12 to 14 cm above the knee
ient on flap and sutured to the shorter lateral Once the major vessels have been joint line with an oscillating power
the sur- flap. In cases of trauma or tumor, isolated, they should be ligated and saw. The location of the cut may vary
supine however, any flap configuration that cut at the proposed level of bone sec- depending on the patient, especially
f the leg will best enha.nce the longest feasible 6on. The major nerves should be dis- with trauma. The blade should be
1 folded residual limb is acceptable. Anterior sected 2 to 4 cm proximal to the pro- cooled with saline. This level is recom-
: hip ex- skin flaps should not be longer than posed bone cut and sectioned with a mended because it allows sufficient
:ing the posterior flaps unless a long medial new, shaTp blade. The central vessel space for placement of the prosthetic
flap is not feasible. If anteriior- can be lightly cauterized or secured by knee joint. Two or three small drill
not used posterior flaps are used, care should a suture around the nerve. Local anes- holes for the purpose of anchoring su-
,utations be taken to minimize the amount of thetic infiltration of bupivacaine by tures a1·e made on the lateral cortex of
: may be subcutaneous tissue dissection to means of a small catheter placed in the distal end of the femur 1 to 1.5 cm
utations. avoid damage to the perforating fas- the nerve is believed to decrease the from the cut end. Additional cortical
,urniquet cia] vessels. Equal anterior-posterior severity of postoperative pain .31 holes are drilled anteriorly and poste-
the thigh skin flaps are unsatisfactory because Muscles should not be sectioned riorly at a similar distance. 27 •29
re setting this places the suture line under the until they have been identified. The The femur is held in maximum ad-
,houJd be end of the residual limb, which may quadriceps is detached just proximal duction while the adductor magnus is
,ion (Fig- lead to problems with prosthetic use. to the patella, retaining some of its brought across the cut end of the fe-
1 the sag- Another disadvantage of equal-sized tendinous portion. The adductor mur while maintaining its tension.
9 The flap flaps is the potential for increased skin magnus is detached from the adduc- The adductor magnus tendon is then

filtra
bupi'
ment
can I
nerv(
for 3
Two
meth
diate
show
ative
duce,
that
domi
infos
resid
ever..
opeir,
in flu
of ar
Figure 8 Attachment of the adductor peri:r
magnus to the lateral part of t he femu r. resid
Figure 9 lntraoperative photograph showing the adductor tendon with sutures t hrough
Courtesy of John Bowker, MD.) tient:
drill holes on t he lateral femur. (Courtesy of John Bowker, MD.)
puta1
investing fascia of the thigh is then su- femoral amputations, and have dis-
tured as dictated by the skin flaps. An tinct disadvantages. The rigid hip
adequate number of subcutaneous su- spica restricts hip mobility, increases
La1
tures to minimize skin tension may be the risk of p ressure sores over bony Cai
used to approximate the skin edges, prominences, and makes postopera- Whi]
and fine nylon sutures (No. 3.0 or 4.0) tive management of patients more tient
or skin staples 29 are used to close the difficult. The use of rigid dressings for chair
skin. T hey should be placed no closer transfemoral amputations has been uppe
Figure 10 Attachment of the quadriceps than 1 cm apart, especially in dysvas- abandoned by many centers. A well- start,
over t he adductor magnus. cuJ.ar patients. The use of forceps on applied elastic bandage will not slip to ha
the skin edges is discouraged. off the residual limb but should be re- to u:
Figures 11 and 12 are postopera- moved and reapplied at least once cont:
sutured with nonabsorbable or long- tive rad iographs showing the femur daily for careful skin inspection be- corn
lasting absorbable suture material to held in adduction by the adductor cause it can shift. bed,
the lateral aspect of the residual fe- myodesis. Figure 13 shows a healed Another method of controlling mus<
mur via the drill holes (Figures 8 and residual limb following transfemoral swelling and reducing discomfort is ditio
9). Additional anterior and posterior amputation. to apply an elastic shrinker with a eral
sutmes are placed to prevent the mus- waist belt. The shrinkers are made of sutu:
cle from sliding forward or backward a one- or two-way stretch material
Early Postoperative prox
on the end of the bone. that applies even pressure distally to for t
With the hip in extension to avoid Care proximally. The waist belt helps pre- weel<
creating a hip flexion contracture, the vent the sh rinker from slipping off cula1
Postoperatively, the residual limb
quadriceps is then sutured to the pos- should be wrapped with an elastic The shrinker may be applied at the pati€
terior aspect of the femur via the pos- bandage, which may be applied as a first dressing change, at 48 hours resid
terior drill holes (Figure 10). These su- hip spica with the hip extended. Al- postoperatively. The use of elastomer ter s
tures may also be passed through the thoug h rigid dressings control edema li ners for control of edema may also justa
adductor magnus tendon. The re- and residual limb position better than be helpful in some patients. ted ~
maining hamstrings are then an- soft dressings do, they are cumber- Postoperative phantom limb pain v\
chored to the posterior area of the ad- some to apply, do not offer any great immediately following surgery is not techi
ductor magnus or the quadriceps. The advantage in the long term in tran s- uncommon and can be reduced by in- early

filtrating the sectioned nerve with

bupivacaine at the time of surgery, as
mentioned earlier. Local anesthetic
can be administered directly to the
nerve continuously or intermittently
for 3 to 4 days and then discontinued.
Two studies31 ' 32 have noted that this
method may be beneficial for imme-
diate relief of postoperative pain and
showed that the amount of postoper-
ative narcotic analgesic could be re-
duced in this way. It should be noted
that neither of these studies was ran-
domized or controlled. Continuous
infusion does not prevent long-term
residual or phantom limb pain, how-
ever. In addition, Jong-standing pre-
operative pain does not appear to be
influenced significantly by any form
of analgesic management. The use of
perineuraJ infusion does not prevent
residual or phantom limb pain in pa-
rough Figure 11 Weight-bearing ra diograph of Figure 12 Radiograph of a residual femur
tients who have had a lower limb am-
a patient wearing a prosthesis to show held in normal anatomic alignment fol-
putation.
alignment of the residual fem ur. low ing adductor myodesis.
e dis-
:i hip
:reases
Late Postoperative
· bony Care
opera- While the wound is healing, the pa-
roore tient should be mobilized in a wheel-
ogs for chair and on the parallel bars, and
; been upper body exercises should be
\ well- started, with the goal for the patient
,ot slip to have sufficient upper body strength
l be re- to use crutches or a walker. Flex:ion
,t once contractures should be p revented by
.on be- correctly positioning tl1e patient in
bed, as well as with initiation of
trolling muscle-strengthening exercises. In ad-
nfort is dition, conditioning of the contralat-
with a eraJ leg is necessary. Most often, the
nade of Figure 13 Healed transfemoral amputation. The suture line is lateral and proximal t o
sutures or staples can be removed ap-
the end of t he residual limb.
material proximately 2 weeks postoperatively
stally to for traumatic amputations and at 3
lps pre- weeks postoperatively in the dysvas- plished in a short time. Patients who The overall rehabilitation of the
,ing off. cu!ar amputee. During this time the do not have tbe physical or mental patient with a transfemoral amputa-
:l at the patient will have been wrapping the ability to participate in a rehabilitation begins at the time of surgery and
8 hours residual limb or using a shrinker. Af- tion program designed to teach pros- co ntinues until the patient has
las to mer ter suture removal, a temporary ad- thesis use will be better off using a achieved his or her individual maxi-
may also justable plastic prosthesis can be fit- wheelchair. Transfer training is im- mum functional independence. Ap-
ted and gait training started. portant in these cases. The decision propriate surgical techniques allow
mb pain With aggressive rehabilitation whether to provide the patient with a techniques for easier prosthetic fitting
ry is not techniques and a motivated patient, wheelchair should be made early in and facilitate physical therapy, help-
ed by in- early return to walking can be accom- the postoperative period. ing the patient achieve the goals tbat

have b een set by the patient and the 12. Thiele B, James U, Stalberg E: Nemo- 24. Van Niekerk LJ, Stewart CP. Jain AS:
t reating team. physiological studies on m uscle func- Major lower limb an1putation follow-
tion in the stump of above-knee am- ing failed infrainguinal vascular by-
putees. Scand J Rehabil Med 1973;5: pass surgery: A prospective study on
References 67-70. a mp utation levels and stump compli-
1. Volpicelli LJ. Chambers RB, Wagner 13. James U: Maximal isometric muscle cations. Prosthet Orthot Int 2001;25:
FW Jr: Ambulation levels of bilateral strength in healthy active male unilat- 29-33.
lower-extremity ampu tees: Analysis of eral above-knee amputees: With spe- 25. Jensen JS, Mandrup-Poulsen T, Kras-
one hu ndred and three cases. J Bone cial regard to the hip join t. Scand J nik M: Wo und healing complications
Joint Surg Am 1983;65:599-605. Rehabil Med 1973;5:55-66. following major amputations of the
2. Hagberg K, Branemark R: Conse- 14. Jaegers SM, Arendzen JH. de Jongh lower limb. Prosthet Orthot Int 1982;6:
quences of non-vascular trans-femora l HJ: Changes in hip muscles after 105-107.
amputation: A survey of q uality of life, above-kn ee amp utation . Clin Orthop 26. Christensen KS. Falstie-Jensen N,
prosthetic use aDd problems. Prosthet l 995;319:276-284. Christensen ES, Brochner-Mortensen
Orthot Int 2001;25: 186-194. 15. Jaegers SM, Arendzen JH, de Jongh J: Results of amp utation for gangrene
3. Gonzalez EG, Corcoran PJ, Reyes RL: HJ: An electromyographic study of the in diabetic and non-d iabetic patients:
Energy expenditure in below-knee hip muscles of t ransfemoral amputees Selection of amputation level using
amputees: Correlation with stump in walking. Clin Orthop 1996;328: photoelectric measurements of skin- ln1
length. Arch Phys Med Rehabil 1974;55: 119-128. perfusion pressure. J Bone Joint Surg
11 1-119. Am 1988;70:1514- 1519. The
l6. Green DL, Morris JM: Role of adduc-
4. Waters RL, Perry J, AntoDelli D, Hislop 27. Gottschalk F: Tra umatic amputations,
ing
tor longus ru1d adductor magnus in
H: Energy cost of walking of ampu- in Bucholz RW, Heckman JD (eds): p ute
postural movements and in ambula-
tees: The influence of level of amp uta- Rockwood and Green's Fractures in func
tion. Am J Phys Med l 970;49:223-240.
tion. J Bone Joint Surg Am 1976;58: Adults, ed 5. Philadelphia, PA. tbesi
17. Inman VT, Ralston HJ, Todd F: (eds):
42-46. Lippincott-Williams &Wilkins, 2001, chaU
Human Walking. Baltimore, MD, Will-
5. Freeman MAR: The surgical anatomy
iams & Wilkins, 1981, pp 102- 117. pp 391 -414. ship:
and pathology of the arthritic k nee, in 28. Molde A: Victin1s of war: Surgical n osi:
18. Jaegers SM, Arendzen JH. de Jongh
Freeman MAR ( ed): Arthritis of the principles must not be forgotten intac
Knee. Berl in, Germany, Springer- HJ: Prosthetic gait of unilateral trans-
femora1 amputees: A kinematic study. (agai n )! Acta Orthop Scand 1998; an d
Verlag, 1980, pp 31-56.
Arch Phys Med Rehabil 1995;76: 281 (suppl):54-57.
6. Hungerford DS, Krackow KA. Kenna 29. Gottschalk F: Transfemoral am puta-
RV: ( eds): Total Knee Arthroplasty: A
736-743.
tion: Biomechanics and smgery. Clin
Re·
Comprehensive Approach. Baltimore, 19. Bolrne W HO : (ed}: Atlas ofAmputa-
MD. \f\lilliams & Wilki ns, 1984, tion Surgery. New York, NY, T l1ieme Orthop l 999;361:15-22. Trc
pp 34-39. Medical Publishers, 1987, pp 79-1 12. 30. Gottschalk F: Above-knee amputation, Bi<
in Murdoch G. Jacobs NA, Wilson AB
7. Maquet PGJ: (ed ): Biomechanics of the 20. Burgess EM: Knee disar ticulation and
(eds): Report of lSPO Consensus Con-
An«
above-knee amputation , in Moore
Knee. Berlin, Germany, Springer-
WS, Malone JM (eds): Lower Extremity ference on Amputat ion Smgery.
Res
Verlag, 1976, p 22.
Amputation. P hiladelphia, PA, vVB Copenhagen, Denmark, International Mo
8. Long IA: Normal shape-normal align-
Saunders, 1989, pp 132-146. Society for .Prosthetics and Orthotics. Care
ment (NSNA) above-knee prosthesis.
1992, pp 60-65. of n
Clin Prosthet Orthot 1985;9:9-14. 21. Harris WR: Principles of amputation
smgery, in Kostuik JP, Gillespie R 3 I. Malawer MM, Buch R, Khurana JS, and
9. Sabolich J: Contoured adducted
(eds): Amputation Surgery and Rehabil- Garvey T, Rice L: Postoperative infu- rect
trochanteric-controlled alignment
itation: The Toronto Experience. New sional conti nuous regional analgesia: aligr.
method (CAT-CAM): Introd uction
York, NY, Churchill Livingstone, 1981, A techniq ue for relief of postoperative men
and basic pr inciples. Clin Prosthet
pp 37-49. pain fo llowing major extremity sur· di arr
Orthot 1985;9:15-26.
22. Barnes RW: (ed): Amputations: An Il- ger y. Clin Orthop 1991;266:227-237.
10. Gottschalk FA. Komosh S, Stills M, rate
McClellan B, Roberts J: Does socket lustrated Manual. Ph iladelphia, PA, 32. Pinzm MS, Garia PG, Pluth T, Vrbos tion
con figuration influence the position o f Hanley & BeJfus, 2000, pp 103-117. L: Con tinuous posto perative infusion tal ,
the femur in above-knee amputation? 23. Mcin tyre KE, Berma11 SS: Patient eval- of a regional anesthetic after an ampu·
perb
J Prosthet Orthot 1989;2:94-102. uation and preparation for an1pu ta- tat ion of the lower ~xtremity: A ran-
tainl
tion, in Rutherford RB (ed): Vascular domized clinical trial . J Bone Joint Surg
11. Gottschalk FA, Stills M: The biome- R
chanics of trans-femoral amputation. Surgery. Philadelphia, PA. WB Saun- Am 1996;78:1501-1505.
plan
Prosthet Orthot Int 1994;18: 12- 17. ders, 2000. pp 2181-2 184. sion
unpc
res id
is ge
50 0 1

Transfemoral Amputation:
{-
l-
;-
lS
;6:
ne
ts:
1- Introduction
The basic goals for fitting and align- cal without anterior pelvic rotation or portant for establishing the initial an-
,ns, ing prostheses for transfemoral am- lordosis. 1 The inability to fully extend gular alignment of the transfemoral
putees are simple enough-comfort, the residual femur usually indicates a prosthetic socket. Proper planning
function, and cosmesis. Achieving hip flex.ion contracture. Because of and incorporation of these angular
these goals, however, is a significant their insertion, the hip flexors have a measurements into the socket and
01, challenge because of the interrelation- mechanical advantage over t he hip overall prosthetic design will facilitate .
ships among patient diagnosis, prog- extensors; therefore, hip flex.ion con- certain biomechanical and alignment
nosis, medical history, residual and tractures are not uncommon and are advantages for the amputee during
intact limb anatomy and kinesiology, especially likely to occur in shorter re- the various phases of gait.
and available prosthetic technology. sidual limbs. This range of motion in
the sagittal plane should be docu- Biomechanics of Knee
a- mented along with other necessary Stability: Stance Phase of
'lin
Review of measurements. Gait
Transfemoral Range of motion in the coronal
Knee stability in a transfemoral pros-
tion, Biomechanics plane consists of abduction and ad-
thesis is defined by the ability of the
AB
Analysis and Relevance of duction of the residual femur. Espe-
Con- cially important is the amputee's abil- prosthetic knee to remain extended
Residual Limb Range of ity to adduct the residual femur as and fully supportive of the amputee
>nal Motion much as the femur on the opposite during the stance phase of walking.
tics, Careful measurement and evaluation side. Normal femoral adduction an- Knee instability is the buckling or un-
of residual and intact limb anatomy gles average about 6°.2 The inability intended flexing of the prosthetic knee
s, and kinesiology are essential for oor- to fully adduct the residual femur during stance. Instability can be quite
fu- rect socket design and initial socket usually indicates an abduction con- dangerous, causing unexpected falls.
·sia: alignment. The necessity for measure- tracture. The add uctors of the femur Excessive knee stability is a condition
ative ment of length, circumference, and are at a mechanical disadvantage in which the knee of the prosthesis is
ir- so stable and resistant to flexing that it
diameter is obvious. However, accu- compared with the abductors because
l7. is difficult for the amputee to initiate
rate evaluation of the range of mo- of their location and the fact that the
bos tion of the residual limb in the sagit- most effective adductors have been the knee flex.ion required for toe-off
sion and swing of the shank, resulting in
tal and coronal (frontal) planes is severed at amputation. Abduction
mpu- high energy expenditure and an un-
perhaps more important and cer- contractures, like hip flex.ion contrac-
an-
tairuy less understood. tures, are not uncommon and are natural swing phase of the gait cycle.
tSurg
Range of motion in the sagittal more prevalent in shorter residual The distinction between knee instabil-
plane consists of flex.ion and exten - limbs. Th is range of motion in the ity and excessive knee stability is very
sion of the residual femur. Especially coronal plane should also be docu- fine. The key to avoiding these two un-
important is the ability to extend the mented. desirable characteristics and achieving
residual femur fully. The normal hip The analysis and measurement of optiornm knee stabi lity is an under-
is generally capable of a maximum of the ranges of motion of the femur in standing of the biomechanics of pros-
5° of extension posterior to the verti- the sagittal and coronal planes are im- thetic knee function.

ing, characteristics common in elderly thesi

and otherwise debilitated amputees. least
Other factors that contribute to invo
control of knee stability include ini- ther,
tial socket flexion, the trochanter- con.t
knee-ankle relationship, and ankle- thes,
foot dynamics. 3 -8 The hip extensor mus
muscles contribute to knee stability yet e
by pulling the prosthetic knee into ex- A
tension or by maintaining existing shoe
knee ex.'tension. The hamstring mus- ties
cles, which are transected by trans- tern.
femoral amputation, are believed to for :
function best when stretched just be- afte1
yond their resting length. The only spo1
fully intact hip extensor, the gluteus that
maximus, is not capable of exerting flexi
a ny significant force until the hip is inst;
flexed at least 15°. 3 -5 To achieve some (Fig
degree of stretching of the gluteus tion
maximus, the prosthetic socket is de- tar
Figure 1 Transfemoral alignment variations and their effect on knee control. A, The
signed for and aligned in a position of 11101
knee axis is placed anterior to the lateral weight reference line to create a voluntary
knee c1mtrol alignment. This alignment has no inherent mechanical stability. B, The initial flexion. The amount of initial tra11
knee axis is placed directly on the lateral weight reference line to create a neutral knee flexion increases as the amputee's corr
control alignment. This alignment is stable during stance but requires voluntary control ability to extend the hip decreases. cate
at heel strike. C, The knee axis is placed posterior to the lateral weight reference line to T he on ly limiting factor is the length
create an involuntary knee control alignment. This alignment is mechanically stable han
of the residual limb. For longer resid- is Oi
throughout stance phase, including heel strike. (Reproduced with permission from Rad-
cliff CW: Functional considerations in the fitting of above-knee prostheses. Artif Limbs ual limbs, some cosmesis has to be case
7955;2:35-60.) sacrificed as initial flexion is in- nes:
creased. In addition to enhancing vol- ind 1
The two biomechanica] descrip- weight-activated stance-control knees, untary control of knee stability, initial
be c
tions of knee stability control are and certain hydraulic knee systems. socket flexion decreases the tendency
ial •
termed involuntary knee control and With voluntary knee control, the of the amputee to increase pelvic lor-
sen
voluntary knee control3 -8 (Figure 1). control is directly subject to the will dosis to compensate for weak hip ex-
her,
With involuntary knee control, the of the amputee and is achieved and tensors. foll,
control is not subject to the will of the maintained through active participa- The trochanter-knee-ankle rela-
gra,
amputee but is automatic. T he degree tion of the hip extensor muscles. tionship is the most common refer-
init
of involuntary control varies in com- These muscles include the gluteal ence for analyzing transfemoral align-
plexity. One form of involuntary knee muscles (primarily the gluteus maxi- ment in the "sagittal plane and is best
control is alignment stability in which mus) and the hamstring muscle understood as the socket-knee-ankle Bi<
the prosthesis (when viewed laterally) group. When these muscles can exert relationship. T he more posterior the Trl
is aligned so that the knee axis is pos- enough fo rce and are consciously knee joint is placed with reference to Ph
terior to the biomechanical weight fired at the proper time by the the socket-ankle line, the more stable
amputee, knee stability is achieved in the knee becomes. In most transfem- Wh
line, which generally extends from the
oral prostheses, the socket is mounted tra1
midpoint of the socket proximally to the stance phase of gait. For the
on an adjustable alignment device goa
the midpoint of foot contact with the stronger and more physically fit am-
putee, voluntary control provides for that permits multidimensional free- Sta\
ground. With the weight line anterior
to the prosthetic knee axis, increased a smoother and more energy-efficient dom of movement of the socket with The
weight bearing tends to force the knee gait because it takes less effort than respect to the knee-shank and ankle- hai
into extension and locks it against the involuntary knee alignment to initiate foot components. (Such an alignment ing
extension stop. Excessive knee stability swing-phase flexion . Better muscle device may later be transferred out of
occms when the prosthetic knee joint tone and coordination are achieved as the finished prosthesis. ) In this ideal drc
is located too far posterior to the bio- wel1. Volw1tary control is not always situation, the AP setting of the socket poi
m echanical weight line. Other fo rms possible, however, particularly when is determined ttnder dynamic condi- mo
of involuntary knee control are me- amputees have muscle weakness or tions as the amputee's gait is analyzed the
chanical, including locking knees, hip flexion contractures or fear fall- carefully. The goal is to align the pros- abc

Chapter 43: Transfemoral Amputation: Prosthetic Managem ent 543
rly thesis so that the amputee uses the

least amount of alignment stability or ~
-'II I'I JW I
a,.. , ~
to
ni-
involuntary knee control necessary,
thereby optimizing voluntary knee
) ~I
CENTER OF GRAVITY , , I _1
11~!i
:er- control. A critical balance between
de- these two biomechanical conditions I I
I
sor must be maintained to achieve a safe I
I
lity yet efficient gait.
ex- Ankle-foot dynamics are the
ing shock-absorbing and stabilizing abili-
lUS· ties of this prosthetic component sys- I
ms- tem. The most unstable phase of gait i:11 ,,
,,'
l to for a transfemoral amputee is shortly lL ----','
be- after heel strike. Dw·ing loading re- l I I
,: i
)IlJy
teus
ting
sponse, a moment or torque is created
that tends to rotate the shin forward,
flexing the knee and thus creating an
Figure 2 At heel strike, a moment or
torque is created that tends to rotate the
:) I: r
f
: lffi :
W I
.p is shin forward and flex the knee, creating :I Ill :I

instant of potential knee instability a:
an instant of potential knee instability. I a: I
ome (Figure 2) . In normal human locomo- (Reproduced with perm1ss10n from I
1
O
a: I, I
!"
1teus t
'
:,
tion, smooth and uninterrupted plan- Anderson MH, Sollars RE (eds): Prosthetic .;
• de- Principles: Above-Knee Amputations. ~I ~ I
tar flexion dampens the significant
: I f
m of
1itial
moment initiated at heel strike. In the
transfemoral prosthesis, ankle-foot
Springfield, IL, Charles C Thomas Publish-
ers, 7960, pp 129-146.) ,' l \
,..-
,' '1
ttee's components that more closely repli- , J...'-,

I
~
'
'r - -· ~)
ases. cate normal ankle- foot function en-
,ngth dius, prevent any additional drop
hance knee stability. If knee stability
esid- through controlled eccentric contrac-
is of particular concern, such as in the Figure 3 Hip abductors can be used to
o be tion. This phenomenon is one of sev- achieve lateral stabilization of the pelvis
case of isolated hip extensor weak-
: m- eral gait determinants designed to only if adequate lateral support is pro-
ness, foot components that reduce the
l vol- provide energy efficiency in normal vided to the femur. (Reproduced with per-
induced knee flexion moment should
nitial locomotion.9 The pelvic shift that mission from Radcliff CW: Functional con-
be considered. Single-axis or multiax- siderations in the fitting of above-knee
iency occurs helps maintain the center of
ial feet or those with a soft heel will prostheses. Artif Limbs 1955;2:35-60.)
c lor- gravity over the base of support, which
serve this purpose well. The goal is in-
.p ex- is a primary goal of gait training for
herent stab ility through early stance, use of a transfemoral prosthesis. perinea! or pubic rnmus pressure and
followed by smooth, uninterrupted, In normal locomotion, weight
rela- discomfort. The amputee will typi-
gradually increasing £1exion through bearing occurs through the bones of cally compensate by widening tJ1e
refer-
initial swing phase. the leg, and contraction of the gluteus base of the gait and using trunk sway
align-
s best medius is effective in controlling pel- over ilie wide-based point of support
·ankle Biomechanics of Pelvis and vic tilt at the hip joint of the stance (compensatory Trendelenburg) to
Jr the Trunk Stability: Stance leg. In the case of the transfemoral maintain a comfortable gait.
nee to Phase of Gait amputee, the femur does not termi- Effective pelvis-trunk stabilization
stable nate in a foot planted firmly on the and a narrow-based gait can be
1sfem- When considering the gait of the ground. The residual femur, now a le- achieved in a transfemoraJ prosthesis
>unted transfemoral amputee, two specific ver no more than 40% of the normal only if adequate lateral support is
device goals are mediolateral pelvis-trunk length of the lower limb, floats in a provided to the femur (Figure 3). The
I free- stability and a narrow-based gait. mass of muscle, tissue, and fluid. The femur must be maintained in a posi-
:t with These interrelated objectives are per- residual femur tends to displace later- tion as near as possible to normal
ankle- haps the most difficult challenges fac- ally in the mass of residual muscle adduction, thereby putting the glu-
runent ing the prosthetist and the amputee. and tissue rather than maintain hori- teus medius and other abductor
'out of In normal locomotion, the pelvis zontal stability of the pelvis and muscles in a position of stretch that
is ideal drops about 5° toward the w1sup- trunk. This lack of support and inef- allows them to function most effec-
socket ported side during midstance; this fective pelvic stabilization resu lts ini- tively. This objective is accomplished
condi- motion occurs around the hip joint of tially in pelvic drop away from the through socket design a nd alignment,
ilaJyzed the weight-bearing limb. 3 -8 The hip prosthetic support leg (positive Tren- with particular attention to the me-
1e pros- abductors, primarily the gluteus me- delenburg's sign), with concurrent dial and lateral walls of the socket.3 -s

D
Figure 4 Illustration of t he lever princi·
pie. W = weight, F = fulcrum, P = proxi- A B
mal part of femur, D = distal part of fe-
mur. (Adapted with permission from Figure 5 Relationship of femoral length to force distribution. A, The greater the femur Figl
Anderson MH, Sollars RE (eds): Prosthetic length, the greater the ability to distribute pressure and forces. B, The short femur is the
Principles: Above-Knee Amputations. subjected to a higher pressure concentration. (Adapted with permission from Anderson the1
Springfield, IL, Charles C Thomas Publish- MH, Sollars RE (eds): Prosthetic Principles: Above-Knee Amputations. Springfield, IL, shi1n
ers, 1960, pp 129-146.) Charles C Thomas Publishers, 1960, pp 129-146.) dev
ittal
exte
In the quadrilateral socket, the proxi- weight and lever lengtll. For example, gait is compromised to achieve the
wel
mal medial wall is flat and vertical to if the lever W-F has an effective primary goal of comfort. mo1
help distribute stance-phase cow1ter- length of 4 in and the force or weight The biomechanica] reaction to the itat
pressure forces; the lateral wall of the is 150 lb, the moment or torque contraction of the hip abductors and sud
socket should be designed and ru·oWld this lever system will be 600 resultant femoraJ force against the lat· eve
aligned in a position of adduction in-lb. If the lever P-D is 10 in, only eral wall of the trans femoral socket is a
that matches the adduction angle 60 lb of force need be exerted to laterally directed force or moment aga
measurement obtained in the evalua- equalize tlle moment or torque of 600 concentrated in the perineum by the m ·
tion of residual limb range of motion. in-lb and thus stabilize the pelvis and proximomedial aspect of the trans· ad,
Restriction of adduction, such as ru1 trunk. However, if the femur lengtl, as femoral socket during midstance. me
abduction contracture, will signifi- simulated by lever P-D is only 5 in When coupled with tlle normaJ and vid
cantly limit the ability to control pel- long, 120 lb of force is required to desirable gait determinant of lateral
vis and trunk stability. Additional equalize tlle 600 in-lb of torque, thus pelvic shift over the support limb, the sig
factors that affect mediolateral pelvis subjecting tlle hypothetical femur to forces generated at tl1e perineum are ity.
and trunk stability include the length much greater levels of pressure. 3 · 5 significant. Firmer, denser, and more foe
of the residual limb, proximomedial T he more evenly and broadly these muscular residual limbs, which are of· pla
tissue density, and proper alignment pressures can be distributed, the more ten longer as well, are better able to nal
of the prosthetic components below tolerab.le they become. If the force is tolerate this reaction force. 10• 12 Soft, cal
the socket. distributed over a smaller area, pres- fleshy (and often shorter) residual vie
A longer residual limb provides a sure concentration may cause dis- limbs lacking muscle tone in the ad-
longer lever and greater surface area comfort, pain, or skin breakdown ductor region are very susceptible to Bi,
over which to distribute the inherent (Figure 5). For this reason, the shorter tissue trauma and bruising and offer a St
forces. In the simple lever system il- the residual limb, the more difficult is less stable reaction point for support.
Pt
lustrated in Figure 4, the effective le- the task of establishing and maintain- In such cases, mediolateral pelvis-trunk
ver arms are W-F md P-D, and resulting mediolateral pelvis and trunk sta- stability will be compromised unless Tb
ing forces or moments depend on bility. In these situations, the ideaJ these reaction forces ru·e directed an

Chapter 43: Transfemoral Amputation: Prosthetic Management 545
ral amputee to attain and the require- ,.vith further developments made by
ments are less demanding than those John Sabolich, Thomas Guth, Daniel
of the stance phase. However, signifi- Shamp, and Christopher Hoyt. 17
cant deviations can result in greater Techniques for fabricating this socket
energy consumption. are similar to those of the quadrilat-
When the prosthesis has too much eral socket; the chief difference is en-
"alignment stability," excess energy casement of the ischiopubic ramus
and effort are required to initiate knee within the socket proper and related
flex:ion. Overcoming such alignment biomechanical and socket comfort
stability takes effort and delays the enhancements.
initiation of swing phase. Vaulting, Hall 18 described five principles of
which is usually regarded as a devia- socket design. Although these were
tion in response to a prosthesis that is intended as design objectives of the
too long, can also serve to subtly quadrilateral socket, they apply
compensate for a delayed advance- equally well to any modern transfem-
ment of the prosthetic shank in mid- oral socket. (1) The socket must be
swing. properly contoured and reliefed for
Swing-phase tracking refers to the functioning muscles. (2) Stabilizing
smoothness of the pathway of the pressure should be applied to the
prosthetic limb during the swing skeletal structures as much as possi-
phase of the gait cycle. Goals are ble, avoiding areas with functioning
to minimize vertical displacement of muscles. (3) Where possible, func-
the prosthesis on the residual limb tioning muscles should be stretched
and to minimize deviations in the to slightly greater than resting length
sagittal plane as the prosthetic limb for maximum power. (4) Properly ap-
femur Figure 6 Alignment devices are between advances during swing phase. Prob- plied pressure is weLJ tolerated by
imur is the transfemoral socket and the pros· neurovascular structures. (5) Force is
thetic knee component and between the lems with vertical displacement stem
derson best tolerated when distributed over
eld, IL, shin and foot. The proximal alignment from poor suspension and resulting
device allows angulation in both the sag- piston action and/or inappropriate the largest available area.
ittal and coronal planes (flexion- prosthesis length. Deviations in the Regardless of the fitting method
extension and adduction-abduction) as employed, the socket for any amputee
ve the sagittal plane include transverse plane
well as linear slide in the same planes of must provide the same overaLJ func-
motion. The distal alignment device facil· "whips" dming the swing phase that
to the itates angulation changes of t he foot, are caused by improper socket shape tional characteristics, including com-
>rs and such as dorsiflexion or plantar flexion, or in1proper knee axis alignment, as fortable weight bearing, stability in
the lat- eversion, and inversion. well as circumduction, which is usu- the stance phase of gait, a narrow-
:ket is a ally caused by excessive prosthesis based gait, and as normal a swing
1oment against more stable anatomic features length or poor alignment. phase as possible consistent with the
by the in this area such as the skeleton. The residual function available to the am-
: trans- advent of the ischial-ramal contain- putee.19 These characteristics provide
:istance. ment transfemoral socket design pro- Transfemoral Socket a context for the following descrip-
nal and vides a solution to this problem. Designs: Variations tion of transfemoral socket designs.
f lateral Prosthetic alignment contributes and Indications Quadrilateral Socket
imb, the significantly to trunk and pelvis stabil-
eum are ity. Controversy exists over socket and The total-contact quadrilateral socket, The term quadrilateral refers to the
1d more foot relationships in the coronal which has both US and European appearance of the socket when viewed
hare of- plane. 13- 15 Foot placement in the coro- variations, was the socket of choice in the transverse plane (Figure 7) be-
: able to from the 1960s until the 1990s but cause there are fo ur readily distin-
nal plane is best determined dynami-
>· 12 Soft, has gradually been replaced by new guishable sides or walls. The orienta-
cally with adjustable alignment de-
residual designs and techniques. 16 In the early tion of the four walls will vary
vices within the prosthesis (Figure 6).
1 the ad- 1980s, innovative designs for trans- according to the amputee's specific
:ptible to Biomechanics of Knee and femoral sockets bega11 to emerge and anatomy and the biomechanical re-
1d offer a were introduced under various acro- quirements of the socket. According
Shank Control: Swing to Radcliffe, 20 "the socket is truly
support. nyms. This basic socket design and
Phase of Gait philosophy has become 1<nown as more than just a cross-section shape
lvis-trunk
ed unless The goals of the swing phase of gait the ischial containment socket. The at the ischial level, it is a three-
directed are normally easier for the transfemo- origin is attributed to Ivan Long, dirnensional receptacle for the stump

Socket shiftod
well forward ot kMe
A~
,c
A
Pos.tenor wall
Figure 8 Socket aligned in initial f lexion
to avoid excessive pelvic rotation during
Figur,
t he latter part of stance phase. (Repro-
duced with permission from Radcliff CW: femo
Functional considerations in the fitting of with
Figure 7 Transverse cross-section of the proximal aspect of a quadrilateral socket. (Cour-
tesy of Northwestern University, Evanston, IL.) above-knee prostheses. Artif Limbs 1955;
2:35-60.) femc
view
with contours at every level which are concept of total smface bearing sug- socket is flat in the sagittal plane mal
justifiable on a sound biomechanica1 gests that weight bearing be as evenly along the proximal 4 inches of the firm;
basis." distributed over the entfre surface socket before reversing proximally at as fe
Weight bearing in the quadrilateral area as possible, with the forces and the brim into a smooth outward flare med:
socket is achieved primarily through loads being evenly shared by skeletal that is directed away from the residual 110,
the ischiurn and the gluteal muscula- anatomy, muscle, soft tissue, and hy- limb and toward the perineum. Care- sity <
ture. This combination of skeletal and drostatic compression of residual ful attention to this proximomedial the 1
muscular a natomy rests on top of the limb fl uids.21 socket contour is absolutely essential AP<
posterior wall of the socket, which is Incorporation of adduction into for stance-phase comfort in the the c
formed into a wide seat parallel to the the quadrilateral socket depends on perineum. versE
ground. Countersupport, intended to the range of motion available, gener- The q uadrilateral socket should be ity ir
maintain the position of the ischium ally a function of the length of the redesigned with initial flexion to im- to UI
and gluteals on this posterior seat, is sidual limb. The goal is to reestablish prove the ability of the amputee to the
provided by the medial third of the the normal adduction angle of the fe- control knee stability at heel contact cally
anterior wall of the socket, which is mur with respect to a level pelvis. The and help m inimize the development T
carefully fitted against Scarpa's trian- quadrilateral socket accomplishes this of lumbar lordosis at toe-off (Figw-e mate
gle. The AP dimension of these re- by contouring the lateral wall in the 8). If this is not done, the amputee the
spective walls is based on anatomic desired degree of adduction. The en- will be tmable to take a full-length quat
measurements. A common error is to tire lateral wall is flattened along the stride on the sound side because of vent
create deep, exaggerated Scru·pa's tri- shaft of the adducted femur with the the limitation in hip extension on the skin
angle contours. As the concepts of to- exception of relief for the distal end prosthetic side. T
tal contact and total surface bearing of the femur. Proximal to the greater The achievement of normal swing quac
became better tmderstood, anterior trochanter, the lateral wall is con- phase depends on several factors. Ob- frorr
counterpressure was deemphasized. toured into and over the hip abductor viously, proper suspension enhanced nific
Clinical experience with other socket muscle group to discourage abduc- by careful matching of residual limb rese,
designs has shown that enlarging this tion. Midstance contraction of the hip and socket contours will aid in StatE
dimension of the socket often allows abductor muscles Leads to reaction achieving a normal swing phase. den,
additional comfort ih the perineum forces occurring in the proximo- Proper socket contours for actively in E
with no loss of comfortable weight medial aspect of the residual l imb and functioning muscles (primru·ily the Eur(
bearing. This suggests that tissue and socket. To provide counterpressure rectus femoris and gluteus rnaximus) brirr
muscle loading occur as a supplemen- and distribute these reaction forces, also affect swing-phase tracking in the StatE
tary weight-bearing mechanism. The the contour of the medial wall of the sagittaJ plane. The depth of the rectus sock

MEDIAL WIDTH OF PAITERN

MEDIAL WIDTH OF PATTERN EQUALS DISTANCE FROM ISCHIAL
EQUALS DISTANCE FROM ISCHIAL TUBEROSITY TO ANTERIOR ASPECT
3'
34
TUBEROSITY TO ANTERIOR ASPECT
OF THE ADDUCTOR LONGUS TENDON
MINUS 0.5 IN. t;' .
'o
,.
3~
3f OF THE ADDUCTOR LONGUS TENDON
MINUS 0.5 IN.
Firm musculature
~
fil. ::e"' ,.
,.3f Soft or average musculature
34
34
SIZE OF PAITERN
SIZE OF PAITEAN DETERMINED BY MEASUREMENT
DETERMINED BY MEASUREMENT OF RESIDUAL LIMB CIRCUMFERENC
OF RESIDUAL LIMB CIRCUMFERENCE AT THE ISCHIAL SEAT LEVEL.
18"
AT THE ISCHIAL SEAT LEVEL 18 .. (j'
2
22"
Posterior
B
<ion
ring
Figure 9 Quadrilateral socket brim pattern variations are affected by res idual limb musculature, particu larly t he gluteals and rectus
pro·
femoris. A, Pattern for a residual limb of soft or average musculature. B, Pattern for a residual limb of f irm musculature. (Reproduced
CW:
with permission from Radcliffe CW: Functional considerations in the fitting of above-knee prosthetics. Artif Limbs 1955;2:35-60.)
gof
955;
femoris channel (in the transverse abrupt than the US-style quadrilateral tissues distal to the pelvis, ie, creation
view) will vary depending on proxi- brin1s. The medioproximal wall was of a "bony lock"; (3) maximal effort
,lane mal circumference and muscular slightly lower to increase comfort in to distribute forces along the shaft of
the firm ness of the residual limb, as well the perineum. In the transverse view, the femur; (4') decreased emphasis on
ly at as femoral anteversion.1 The postero- these European brims featured a a narrow AP diameter between the
flare medial wall angle varies from 5° to larger AP dimension balanced by a adductor longus-Scarpa's triangle and
idual 11°, depending on the muscular den- smaller mediolateral dimension tl1an ischium for the maintenance of
:::are- sity of the proximoposterior aspect of typical US-style quadrilateral shapes. ischial-gluteal weight bearing; (5) to-
1edial the residual limb 1 (Figure 9) . If the Although the biomechanical p rinci- tal contact; and (6) use of suction
~ntial AP dimension of the lateral half of ples remained the same, these subtle socket suspension whenever possible.
the the quadrilateral socket viewed trans- changes began to influence US quad- Weight bearing in the ischial con-
versely is too tight, then muscle activ- rilateral techniques near the time tainment socket is foc used primarily
1ld be ity in the swing phase of gait can lead when the ischial containment socket through the m edial aspect of the isch-
) im- to undesirable socket rotations about introduced new concepts in transfem- ium and the ischial ramus. 19 The
tee to the residual limb that appear clini- oral socket theory. socket encompasses both the ischial
)ntact cally as swing-phase "whips." tuberosity and the ramus; the specific
)ment The distal end of the socket must lschial Containment Socket contour depends on the m usculature,
Figure match the contour of the distal end of The term ischial containment is self- soft tissue, and skeletal structure of the
1putee the residual limb and provide ade- de$criptive, referring to several simi- amputee. 11 •12•23 Unlike the quadrilat-
length quate distal contact in order to pre- lar concepts in socket design in which eral socket, in which the proximal con-
use of vent development of edema and other the ischium (and in some cases the tours are affected primarily by muscu-
on the skin problems. ischial ramus) are enclosed within lar variation, proximal contours of the
T he basic concept of the US-style the socket. Pritham 22 described six ischial containment socket are affected
swing quadrilateral socket was borrowed objectives that would be achieved in by differences in pelvic skeletal anat-
rs. Ob- from Europe and refined through sig- the ideal ischial containment socket: omy. Of particular importance are the
hanced nificant biomechanical analysis and ( 1) maintenance of normal femoral variations in the position of the is-
al limb research conducted in the United adduction and narrow-based gait chium with respect to the trochanter
aid in States. 20 The original concept also tm- during ambulation; (2) enclosure of (Figure 10). In females, the ischia are
phase. derwent simultaneous development the ischial tuberosity and ramus in positioned more lateralJy, closer to the
actively in Europe. During the 1980s, several the socket to varying extents medially trochanter, to allbw for childbearing.
:ily the European-style quadrilateral casting and posteriorly so that forces involved The posterior brim of the socket is
1ximus) brims became available in the United in maintenance of mediolateral stabil- proximal to and tightly posterior to
1g in the States. T he transitions from the fo ur ity are borne by the bones of the pel- the ischium. Countersupport, in-
.e rectus socket walls were smoother and less vis medially and not just by the soft tended to keep the ischium and ram us

sure from the trochanter anteriorly to Fle'4

the tensor fascia latae. 11 • 12•23 Addi- Socl
tional weight-bearing support is
1n 15
thought to be provided by the gluteal
duce,
musculature and the lateral aspect of
socki
,, I
I
the femur d.istal to the trochanter, as
State
,,, ,,, well as from pressures distributed as
I I
The Skeletal M-L ISN'l:

The Soft Tissue M-L evenly as possible over the entire sur-
and~
face of the residual limb. 15 • 19 Because
: I
-,.TheSoft TISsueM•L I I
~ t I thesE
The Skelelal ~ significantly more residual limb sur-
favo1
face and volume are contained within
flexil
the ischial containment socket than in
sock,
the quadrilateral socket, identical re-
A rigid
sidual limbs have greater force distri-
tainE
bution and hence lower pressures with
an ischial containment design.
may
One hypothesis is that the quadri- may
lateral socket is displaced laterally plast
during midstance and thus results in ing
a shearing force on the perjneal tis- said,
The Skeletal M-L sues. Secondarily, femoral abduction wou
The Soft Tissue M-L may occur and decrease the effective- defo
ness of the gluteus medius. The solu- teria
tion provided by the iscbial contain- stret
ment socket is to extend the medial jectE
brim of the socket proximally until that
B pressure is brought to bear against the sys ti
medial ischiopubic ramus. The result- com
ing force couple between the ischium, fran
trochanter, and laterodistal aspect of cap,
the femur is believed to provide a sod
much more stable mechanism for ac- mat
The Skeletal M-L ceptance of perinea! forces, leading to nati
The Soft Tissue M-L increased comfort in the groin and and
better control of the pelvis and reac
trunk 15 (Figure 11). }
Stance stability may be enhanced by van

extensive contouring posterior to the incr
femoral shaft; this allows more effec- cep1
c tive transmission of the movements of tecl
the femu r to the prosthesis. 15 nor
Figure 10 Variations in the proximal design of ischial containment sockets are based on Swing-phase suspension is critical date
pelvic structure and diameter and soft-tissue diameter just distal to the pelvis. Variations and is usually achieved by suction. As han
are individual and are most significant between males and fema les. M-L =medial-lateral with the quadrilateral socket, proper the
diameter of the skeleton at the ischial level. (Reproduced with permission from Hoyt C, contours allow for smooth swing- flex
Littig D, Lundt J, et al: The UCLA CAT-CAM Above-Knee Socket, ed 3. Los Angeles, CA,
UCLA Prosthetics Education and Research Program, 1987, p 15.)
phase tracking. Rotational control is lim
provided by the proximomedial brim be
and its bony lock against the ischium, resi
solidly against the medioposterior as- through the distal mediolateral di- the shape and channels of the ante- tio1
pect of the socket, is produced in three mension, a soft-tissue measurement rior wall, and the posttrochanteric anc
ways. First, the skeletal mediolateral that reflects the d iameter of the resid- contours of the lateral wall as seen in
dimension-the distance between the ual limb 1 to 2 inches distal to the skel- the transverse view15•23 (Figure 12). So
medial aspect of the ischium and the etal mediolateral dimension. The third Control of socket rotation for very Tn
inferolateral edge of the trochanter- form of countersupport, most impor- fleshy residual limbs with poor mus-
must be carefully designed into the tant in females because of their pelvic cle tone is best achieved with an is- Ho
socke.t. Second, countersupport occurs anatomy, is anterolateral counterpres- chial containment socket. cor

I to Flexible Transfemoral
ldi- Sockets
is In 1983, Kristinsson of Iceland intro-
teal
duced the concept of the flexible
t of 24
socket design. Known in the United
:, as
States under various acronyms such as
i as
ISNY (Icelandic-Swedish-New York)
sur-
andSFS (Scandinavian Flexible Socket),
mse
these techniques gained considerable
sur-
favor. 22 •25•26 The concept incorporates
thin
flexible thermoplastic vacuum-formed A
.n 111
sockets supported in a rigid (or semi-
l re- Figure 11 AP view of quadrilateral and ischial containment sockets. A, The quadrilat-
rigid) fenestrated frame or socket re-
stri- eral socket lacks a proximal bone lock and hypothetically allows lateral socket displace-
tainer (Figure 13). The socket retainer
with ment during stance phase. Pelvic stability is compromised. B, In the ischial containment
may be made of laminated plastic or socket, the ischial tuberosity is locked in the socket. The resu lting bony lock between
may be vacuwn formed of thermo- the ischium, trochanter, and lateral distal aspect of the femur provides a much more sta-
adri-
plastic material (Figure 14). Describ- ble mechanism for acceptance of the perinea! biomechanical forces. (Reproduced with
:rally permission from Michael JW: Current concepts in above-knee socket design. Instr Course
.ts in ing a flexible socket, Kristinsson27
Leet 1990;39:373-378.)
1 tis- said, 'To label a socket as flexible I
ction would say that you should be able to
:tive- deform it by your hands, and the ma-
solu- terial should not be elastic enough to
ttain- stretch under the loads it will be sub-
1edial jected to." Kristinsson also indicated Anterior
that when designing a flexible socket Scarpa's
until ,r- Rectus femoris
triangle~
st the system, the most critical aspect for the channel
esult- comfort of the wearer is how the
bium, frame is designed. The frame must be Medial
ect of capable of supporting the flexible
- - Posttrochanteric
,ide a socket, preventing permanent defor- channel
lschial
or ac- mation, and the socket-frame combi-
pubic ramus
.ing to nation has to be structurally strong
o and and stable enough to counteract the A B
; and reaction forces. 27
According to Pritham, 22 the ad- Figure 12 Rotational control of the ischial containment socket is provided by the prox-
cedby vantages of flexible wall sockets are imomedial brim and its bony lock against the ischium, the shape and channels of the an-
to the increased comfort, improved proprio- terior wall, and the posttrochanteric contour of the lateral wall. A, Medial view, sagittal
plane of the ischial containment socket. B, Transverse view, ischial containment socket.
• effec- ception, use of conventional fitting
(Reproduced with permission from Pritham CH: Biomechanics and shape of the above-
ents of techniques, the ease with which mi- knee socket considered in light of the ischial containment concept. Prosthet Orthot Int
nor volume changes are accommo- 1990; 14:9-21.)
critical dated, temperature reduction, and en-
ion. As hanced suspension. He believes that the new socket designs introduced in at odds but rather are separate but re-
proper the general indications for use of a the 1980s were associated with stri- lated entities in a continuum labeled
swing- flexible socket are a mature residual dent claims for their benefits, coupled above-knee sockets."
11trol is limb, for which socket changes would with concurrent denigration of the In a similar vein, Michael 16 con-
al brim be infrequent, or a medium to long quadrilateral design. According to tends that these new designs represent
;chium, residual limb, where a significant por- Pritham and associates, 28 "most if not evolutionary, rather than revolution-
.e ante- tion of the wall can be left exposed all of the major factors influencing ary, advances. In reality, socket design
ianter ic and flexible. the shape of the newer sockets can be indications can only be offered from
seen in explained in terms of the principle of shared clinical experience and work-
ue 12). Socket Indications: Current ischial containment, and .this princi- shops10 because there are no impar-
or very Trends
ple is fully compatible with Radcliffe's tial field tests or objective scientific
) r mus- biomechanical analysis of the func- studies produced to date to provide
11 an is- How is the clinician to sort out these tion of the quadrilateral socket. The answers to this question. The fo llow-
conflicting philosophies? 16 Some of varying socket configurations are not ing information can be summarized

Several additional factors should

be considered. One concern regarding
the ischial containment technique is
the difficulty of efficiently obtaining a
successful fit. 16 Initially, repeated test
or tTial sockets were the norm for this
technique; in contrast, the quadrilat-
eral technique rarely required more
than one initial test socket. Increased
experience among practicing prosthe-
tists and the incorporation of instruc-
tion on the technique into prosthetic
education program curricula has
tended to level the differences be-
tween the two techniques. Today, is-
chial containment techniques have
come to be widely accepted and are
used to an ever-increasing degree.
The use of thermoplastics in pros-
thetic socket design is on the rise and
offers some significant advantages
I over conventional lam inated plastic
I sockets. 29 Flexible sockets are, how-
I ever, less durable than rigid laminated
sockets. Thermoplastic materials by
their very nature will creep and
change shape over time when sub-
c D jected to continuous loads, particu-
larly at body temperatme. Amputees
Figure 13 Flexible socket, rigid socket frame design variations. A, Durr-Fillauer's Scandi- and others who advocate the use of
navian Flexible Socket {SFS) is shown from t he posterolateral {left) and anteromedial flexible sockets must be prepared for
(right) aspects. B, Sabolich-style frame with a totally flexible brim for use with an ischial the reality that the flexible socket will
containment socket. C, Frame for an ischial containment-style socket with a posterior gradually lose its fit and require more
seat, support pad posterior to the greater trochanter, and a distal support flange ro-
tated posteriorly so that it supports the posterolateral end of the femur. D, Frame simi-
frequent replacement.
lar to that shown in C but with an anterior extension supporting the lateral support FigurE
pad, thus providing total flexibility posteriorly. The frame is trimmed below the trim line Socket Fitting Techniques oral e
of t he socket and thus provides a totally f lexible brim. (Reproduced with permission The prosthetist must carefully mea- socke·
from Pritham CH: Above-knee flexible sockets: The perspective from Durr-Fillauer, in sure and record a variety of data de-
Donovan R, Pritham C, Wilson AB Jr (eds): Report of ISPO Workshops, International mow
Workshop on Above-Knee Fitting and Alignment. Copenhagen, Denmark, International
scribing a patient's residual limb. This
Society for Prosthetics and Orthotics, 7989, pp 26-27.) data is used to generate the specifica- puteE
tions for production of a socket to brim
meet the needs of the patient. A vari- place
from the work of a panel of physi- residual linlbs; (5) ischial contain- ety of methods are currently used for rated
cians, prosthetists, a11d engineers who ment sockets are the better recom- this puTpose. AJ
participated in an international work- mendation for high-activity sports The introduction of laminated "han
shop on transfemoral fitting and participation; (6) no consensus was plastic, total-contact sockets (sup- limb,
alignment: 1 t, 12•16 (1) No specific con- reached on the best recommendation planting wood, open-ended sockets) aids.
traindications were noted for any for the bilateral transfemoral ampu- also led to the adoption of the use of co1ru
socket design; (2) some advocated no tee; (7) flexible-wall sockets are not Plaster of Paris bandages to obtain a men1
change for successful quadrilateral linked to any one philosophy of trans- negative wrap cast of the patient's Tl
socket wearers; (3) quadrilateral sock- femoral socket design; and (8) total limb. A positive model is generated aidec
ets are most successful on long, firm flexible brin1s are essential to the suc- from this and the actual socket is factu
residual limbs with firm adductor. cess of max:in1al ischial-ramal contain- formed about this model. A variety of lowe
musculature; (4) ischial containment ment sockets. In general, clinical prac- casting aids is available to selectively intrc
sockets are more successful than tice has borne o ut the efficacy of these mold the wrap cast during the casting actio
quad rilateral sockets on short, fleshy guidelines. process. These aids include a floor- can l

11d
socket template stored in the comput- Suction Suspension
er's memory can be selected. Design Suction suspension is typically ef-
ng
paradigms created by the software de- fected by an air e:i.-pulsion valve in the
is
signer modify the template to reflect distal end of the socket combi ned
~a
est the patient's measurements. The re- with a precisely fitted socket. Negative
his sulting data are used to carve a positive air pressure suspends the prosthesis
at- socket model. This method is faster, during swing phase. The socket is
:>re cleaner, and Jess tiring for both pros- sealed around the residual limb di-
,ed thetist and amputee than the plaster rectly against the skin, without the
be- cast methods described above. It bas use of prosthetic socks.
uc- been hypothesized that consistent re- The prosthesis is typically donned
etic sults are more readily obtained, partic- by one of two methods. Most com-
has ularly in achieving the more complex monly, the an1putee pulls the residual
be- geometry of the newer socket config- limb into the socket by applying a
is- urations. length of open-ended stockinette
Lave Regardless of how the positive around the residual limb, putting the
are model is obtained, in all likelihood it end of the stockinette through the
will be used to produce a check or test valve hole at the distal end of the
ros- socket. Such trial sockets a1e used to socket, and pulling tl1e residual lin,b
and refine the characteristics of the rela- down into the socket. In tl1e process
ages tionship between the socket and the of pulling the residual limb com-
~stic patient and to ensure that both the pletely into the socket, the stockinette
lOW- patient and the prosthetist are satis- is gradually removed from the socket.
ated fied with the result. The advent of is- This donning procedure requires
i by chial containment sockets with their some skill and effort. Balance prob-
and more intimate fit about the structures lems, upper limb deficiencies,
sub- of the pelvis weighs heavily i11 favor of strength deficiencies, heart problems,
ticu- using a test socket. and other conditions can contribute
LItees
Test sockets and realignable en- considerable difficulty to this method
se of doskeletal components lend them- of donning, and at one time were
d for
selves to fabrication of prototype considered contraindications for suc-
twill
prostheses. A prototype prosthesis can tion suspension.
more
best be described as a precursor to the An easier method of donning a suc-
prosthesis eventually inte11ded for the t ion socket is with the use of hand
Figure 14 Anterior view of left transfem-
~s patient's long-term use. It is fabri- creams or lotions. A lubricating agent
oral exoskeletal prosthesis with a flex ible
socket-rigid socket frame design . cated in a temporary fashion using is spread either on the residual limb or
mea-
the test socket and endoskeletal com- inside the brim of the socket so that
:a de·
mounted apparatus in which the am- ponents (kn ee, foot, etc) to dynami- the amputee can push the residual
. This
putee stands and simpler casting cally assess the function of the socket limb into the socket. After the limb is
:ifica-
brims that are manually supported in and other components during gait as completely in the socket, the valve is
<et to
place by the prosthetist and incorpo- well as to complete the dynamic used to expel air and suction is
, vari·
ed for rated in the cast. alignment prncess. If a component achieved. Within a short period of
Alternately, the prosthetist can proves to be less than optimal, the time, the lotion is absorbed into the
inated "hand cast" the patient's residual prescription can be altered before the skin . This method of donning a suc-
(sup· limb, without reliance on external actual prosthesis itself is fabricated. tion socket has expanded the applica-
,ckets) aids. This course of action is most tion of such suspension. Some pa-
common when fitting ischial contain- tients, however, find the use of lotion
use of Suspension Variants messy and unappealing. In addition,
,tain a ment sockets.
1tient's The proliferation of computer Improper suspension results in poor soft tissues tend to be displaced prox-
1erated aided design/computer aided manu- gait, decreased safety, and increased imally during the donning process. If
:ket is facturing (CAD/CAM) technology in skin problems. Secure and depend- the socket is too tight, this can create
:iety of )ower limb prosthetics bas led to the able suspension enhances propriocep- an adductor roll, a roll of flesh trapped
!ctivelY introduction of yet another comse of tion and control and creates the feel- between the medial brim of the socket
casting action. Data about the residual limb ing that the prosthesis is more a part and the bones of the pelvis. Adductor
floor· can be entered into a computer and a of the wearer. rolls can eventually cause considerable

cotton webbing, or Dacron. The belt Ca

is attached to a pivot point on the
socket in tl1e area of the greater tro- WhE
chanter and passes around the back pros
and over the opposite iliac crest, crite
where it achieves most of its suspen- mos
sion. Anteriorly, it attaches at either a expE
single point or, in some cases, double guir
attachment points (Figure 15). This men
belt provides a positive form of sus- dud
pension of the prosthesis and is sim- voe,
ple to use. The disadvantages of the rabi
B Silesian belt are that it is usually not com
removable for washing, and there is thet
Figure 15 Two methods of suspension of t h e t ransfemoral prosthesis. A, Silesian belt . sometimes discomfort associated with isfac
B, Hip joint, pelvic band, and waist belt. (Reproduced with permission from Wilson AB constrictive waist belts. chat
Jr: Limb Prosthetics, ed 6. New York, NY, Demos Publications, 1989, p 58.) wit}
A number of simpler removable al-
ternatives are now commercially put<
sign
discomfort and are quite difficult to Suspension Liner available and have been well accepted
succ
reduce once they have formed. clinically. These products were origi-
In recent years, prefabricated suspen- 1
Suction suspension is usually indi- nally made of elastic neoprene mate-
sion liners and locking mechanisms ind
cated for amputees with smooth re- rial lined with a smooth nylon mate-
have been used increasingly with and
sidual limb contours. Volume fluctua- rial but are also fabricated from
transfemoral amputees. These devices eleIJ
tions such as weight gain or loss or lightweight open mesh fabric. This
afford many of the advantages of the illm
fluid retention problems are contrain- type of suspension belt fits around
traditional suction socket, while cou
dications for suction sockets. With the proximal portion of the prosthesis
avoiding the primary disadvantage of eve1
the advent of ischial containment and then around the waist and fastens
the difficult donning techniques. SUC(
sockets, even very short amputation anteriorly with Velcro (Figure 16).
The various locking mechanisms tior
limbs can often be successfully fitted do take up space distal to the socket. This belt is quite comfortable and for-
with suction as a primary suspension. For longer residual limbs, this may re- giving because of its elasticity. It pro- Ca
Additional auxiliary belt suspension sult in d isplacement of the knee vides reasonably good suspension and
A2
is generally prudent. Suction suspen- enhances rotational control of the
mecha nism distally in the prosthesis alo
sion can be used together with any of and comprorn_ised cosmesis. Suspen- prosthesis. Disadvantages include
the
the other forms of suspension. sion liners demand meticulous hy- body heat retention and limited dura-
mu
Suction suspension of transfemo- giene to avoid undesirable odors and bility; however, the open mesh fabric
!em
ral prostheses provides the best pro- skin irritation. variations should dissipate heat more
and
prioception. The suspension is ap- Suspension is achieved through readily.
soc
plied directly to the residual limb, contact between the inside of the wer
rather than from belts around the Hip Joint With Pelvic Band
roll-on liner and the soft tissue of the em·
waist; the skin is in direct contact residual limb. If the limb is fleshy, dis- and Belt
with the socket; and the movements tal displacement of the prosthesis The hip joint with pelvic band and Re
of the limb are transmitted to the during swing phase can occur, mak- waist belt provides rotational stability Mo
prosthesis with minimal lost motion. ing the prosthesis functionally too plus a significant degree of mediolat- the
Disadvantages include difficulty ob- long dw·ing swing phase. This prob- eral pelvic stability. This is sometimes US\l
taining the required precise fit, occa- lem can be minimized with a tether necessary in obese amputees or for ti.01
sional loss of suction in sitting or system to elongate the residual limb those with significant redw1dant tis- pul
other positions, lack of a medium for during donning, or by employing a sue that is difficult to stabilize. This ner
absorbing perspiration, skin shear, method to secure the liner proximally. suspension is particularly useful for rot
and the requirement of weight and the patient with weak hip abductors na1
volume stability. Partial suction sus- Soft Belts (Figure 15). Because most amputees pre
pension, which uses the principles de- Soft suspension belts may be used as object to the weight and bulk of this the
scribed above with a thin prosthetic either primary or auxiliary suspen- suspension, it is generally reserved for of1
sock or nylon sheath, sometimes sion. The traditional form of soft belt cases in which rotational control or car
eliminates or minimizes the disadvan- is the Silesian belt or bandage, a flexi- mediolateral stability cannot be km
tages. ble, soft belt usually made of leather, achieved in any other manner. cor

Chapter 43: Transfemoral Amputation: Prosthetic Managem ent 553
control system with integrated force

belt case Studies sensors in the shin tube component. A
the When recommending transfemoral less desirable alternative would be a
tro- prosthetic components, two sets of polycentric knee with hydraulic or
>ack criteria may be applied. The first and pnewnatic swing control.
rest, most important set includes previous
>en- eiq,erience of the amputee, safety re- Rationale
L
er a quirements, and functional require- Suction suspension is ideal for active
uble ments. Secondary considerations in- amputees and is enha11ced by a long,
This clude the level of amputation, muscular residual limb. A flexible
sus- vocational and avocational needs, du- socket is more forgiving for the ac-
sitn- rability of components, weight of tive athlete and thus more comfor t-
: the components, cosmesis, and cost. Pros- able. The cosmesis afforded by an en-
· not thetic components that have been sat- doskeletal prosthesis with soft cover
re is isfactory in the past should not be meets the social and vocational needs
with changed without thorough discussion of this amputee. A microprocessor-
with the amputee. The longer an am- controlled hydraulic stance and swing
le al- putee has worn a specific system, de- I
control knee allows the most natural
:ially sign, or component, the less likely the
I
gait and the greatest stability. This
!pted success of a change. knee facilitates functional activities /
>rigi- The following case presentations such as descending stairs step over
nate- include prosthetic recommendations step, negotiating downhill inclines,
nate- and a rationale for each prescription and controlled knee flexion when
from element. These cases are intended to seated. The 4-bar polycentric knee, if
This illustrate approaches commonly en- chosen, provides inherent stability
ow1d countered in prosthetic practice; how- during the critical stance phases of
thesis
ever, other prescriptions may wen be activity, is smooth in swing; and is Figure 16 Total elastic suspension belt
1stens successful in similar clinical situa- compatible with long amputations. made of neoprene and Velcro. (Courtesy
16). Either pneumatic or hydraulic knee .
tions. of Syncor, Ltd.)
d for- control is essential for varying ca-
t pro- Case Study 1 dences, a11d the dynamic-response weight-activated stance control knee
n and A 29-year-old woman presented with foot provides better propulsion and and single-axis, flexible keel foot and
,f the ankle is also recommended.
a long left transfemoral amputation at response during all activities.
1clude the supracondylar region of the fe-
dura- mur. She had no other health prob- Case Study 2 Rationale
fabric lems, had normal range of motion A 78-year-old man presented with a Stability is a primary concern because
more and strength, and was athletically and midthigh right transfemoral amputa- of the combination of weakness and
socially active. Her preferred sports tion and a history of peripheral vas- poor vision. The weight-activated
were tennis and racquetball. She was cular disease secondary to diabetes stance control knee provides safety
md mellitus. His left lower lin1b had vas- and knee stabilization during stance,
employed as an attorney's assistant.
cular disease involvement and was yet flexes quite easily for swing and
.d and Recommendation weak and insensate. He had decreased sitting. The amputee's gait will be
ability Most prosthetists today would opt for strength and range of motion of the slow because of the comorbidities.
diolat· the ischial containment socket design, residual limb. His eyesight was failil1g The single-axis, flexible keel foot al-
.etimes usually with a flexible brim and suc- as well. He was retired and desired lows rapid footflat in early stance,
or for tion suspension incorporating an ex- household ambulation for limited thereby enhanci11g knee stability. The
mt tis· pulsion valve. An endoskeletal compo- distances. flexible keel permits smooth rollover
e. This nent system including a transverse with less effort in terminal stance.
fol for rotational torque absorber a11d dy- Recommendation Minimization of weight reduces the
iuctors namic response foot would also be ap- A semiflexible thermoplastic quadri- effort involved in ambulation.
1putees propriate. The critical component is lateral socket fit with thin prosthetic
of this the knee, which determines the range socks and a soft suspension belt of Case Study 3
ved for of normal activities of daily living that neoprene or spandex are suggested. A 15-year-old boy presented with a
.trol or can be safely accomplished. The ideal Use of a roll-on locking liner could right transfemoral amputation at the
ot be knee would be a microprocessor- also be considered. A lightweight en- proximal third of the femur second-
controlled hydraulic stance and swing doskeletal component system with ary to cancer. The boy was very

healthy and active, participated in Recommendation alignmen t of the lower extremity. JS.Sa
junior varsity basketball and baseball, A quadrilateral socket and thin cotton J BonefointSurgAm 1987;69:745-749. tr<
and was also an avid hunter and fish- 3. Anderson MH, Sollars RE (eds): Pros- m
sock fit with a valve for partial suc-
erman. He was described as "growing thetic Principles: Above-Knee Amputa- a11
tion are advised. Silesian belt suspen- Q;
like a weed." tions. Springfield, IL, Charles C Tho-
sion is preferred. An exoskeletal de- mas Publishers, 1960, pp 129-146. 16.M
sign, swing-and-stance control knee, 4. Anderson MH, Solla rs RE (eds): Man -
Recommendation al:
and a simple, maintenance-free, con- ual ofAbove-Knee Prosthetics for Physi- Lt
An ischial containment flexible socket forming foot such as a flexible keel cians and Therapists, ed 2. Los Angeles, 17. W
with a rigid socket retainer and suc- foot should be considered . CA, UCLA School of Medicine, Pros- dt
tion · suspension is recommended, thetics Education Program, 1957, pp dt
with the option of auxiliary suspen- Rationale 86-104. SC
sion in a removable soft neoprene or The quadrilateral socket is familiar to 5. Anderson MH, Sollars RE (eds): Man- sh
spandex belt. An endoskeletal system this amputee and, when properly fit- ual ofAbove-Knee Prosthetics for Physi- Ki
with hydraulic knee control (prefera- ted, is quite satisfactory for the mus- cians and Therapists, ed 2. Los Angeles, c
bly swing and stance control) is ad- cular rnidthigh residual limb. The CA, UCLA School of Merucine, Pros- S<
vised, along with a carbon fiber thetics Education Program, 1957, pp l!
partial suction socket with a cotton
95-111.
shank-ankle-foot for maximum dy- sock provides a medium for absorp- 18. H
namic response. A torque absorber 6. Radcliffe CW: Biomechanics of above- rt
tion of perspiration and offers secure
knee prostheses, in Murdoch G (ed): aJ
should also be considered. suspension when coupled with the Prosthetic and Orthotic Practice. Lon-
Silesian belt. The exoskeletal con- 19. R
don, England, Edward Arnold, 1970,
Rationale struction is durable for repeated Cl
pp 191-198.
v:
An ischial containment suction socket kneeling and similar occupational re- 7. Radcliffe CW: Functional consider- R
is indicated by both the short residual quirements. The swing-and-stance ations in the fitting of above-knee \A
femur and high activity level. The hydraulic knee provides stability and prostheses. Artif Limbs l 955;2:35-60. A
flexible socket enhances comfort and safety options that serve his voca- 8. Radcliffe CW: The Knud Jansen Lec- It
suspension, and the optional auxiliary tional needs. The foot is simple and ture: Above-knee prosthetics. Prosthet a:
suspension provides additional secu- d urable and conforms well to varying Orthot Int 1977;1:146-160.
rity for high-demand activities. The terrain. 9. Saunders JB, Inman VT, Eberhar t HD:
endoskeletal construction readily ac- The major determinants in normal
commodates linear growth, and the and pathological gait. J Bone Joint Surg
swing-and-stance hydraulic knee con-
Summary Am 1953;35:543-558.
trol offers many options, including a The controversy created by the signif- 10. International workshop on above-
knee-locking option for hunting and icant changes in the management of knee fitting and alignment, Workshop
ambulating in rough terrain. The car- transfemoral amputees that occurred on teaching material for above-knee
in the 1980s was largely resolved in socket variants, in Donovan R,
bon fiber shank-ankle-foot provides
Pritham C, Wilson AB Jr (eds): Report
maximum possible dynamic response the 1990s as a result of clinical experi-
of ISPO Workshops, International Work-
for demanding sports activities in ad- ence and consensus. Through the use
shop on Above-Knee Fitting and Align-
dition to dependable durability, and of new materials, components, and ment (Appendix C). Copenhagen, Den-
the torque absorber reduces shear designs, the transfemoral amputee to- mark, International Society for
stresses to the residual limb. day can achieve a much higher activ- Prosthetics and Orthotics, 1987.
ity level than was possible in the past. 11. Schuch CM: Modern above-knee fit-
Case Study 4 The fundamental goals of providing ting practice: A report on the lSPO
A 38-year-old man presented with a comfort, function, and cosmesis con- Workshop on Above-Knee Fitting and
muscular midthigh left transfemoral tinue to guide clinical practice and Al ignment Techniques. Prosthet Orthot
amputation. The cause of the amputa- the development of new techniques Intl 988;12:77-90.
tion was a motor vehicle accident. He and components. 12. Schuch CM: Report from: Interna-
had worn several prostheses, all quad- tional workshop on above-knee fitting
and alignment techniques. Clin
rilateral socket designs. He worked as a References Prosthet Orthot 1988;12:81 -98.
framing carpenter, climbing ladders
l. Total Contact Socket for the Above-Knee 13. Long I: Allowing normal adduction of
and scaffolding. Because heat and per-
Amputation ed 5. Los Angeles, CA, femur in above-knee amputations:
spiration are a chronic problem in the UCLA School of Medicine, Technical note. Orthot Prosthet 1975;
climate and his work, he requested a Prosthetics-Orthotics Education Pro- 29:53-54.
socket fit with prosthetic socks. He was gram, 1976, p 19. 14. Long IA: Normal shape-normal align-
very strong and agile and depended on 2. Moreland JR, Bassett LW, Hanker GJ: ment (NSNA) above-knee prosthesis.
the prosthesis for his work. Radiographic analysis of the axfal Clin Prosthet Orthot 1985;9:9-l 4.

15. Sabolich J: Contoured adducted 20. Radcliffe CW: A short history of the knee socket, in Donovan RG, Pritham
9. trochanteric-controlied alignment quadr ilateral above-knee socket, in C, Wilson AB Jr (eds): Report of ISPO
S· method (CAT-CAM): Introduction Donovan R, Pritham C, Wilson AB Jr Workshops, International Workshop on
and basic principles. Clin Prosthet (eds): Report of ISPO Workshops, Inter- Above-Knee Fitting and Alignment.
Orthot 1985;9:l 5-26. national Workshop on Above-Knee Fit- Copenhagen, Denmark, International
J6. Michael JW: Current concepts in ting and Alignment. Copenhagen, Den- Society for Prosthetics and Orthotics,
above-knee socket design. Instr Course mark, International Society for 1987, pp 20-23.
tn-
;i- Leet 1990;39:373-378. Prosthetics and Orthotics, 1987,
26. Fishman S, Berger N, Krebs D: Ab-
pp 4-12.
.es, 17. Wilson AB Jr: Brief history of recen_t stract: The ISNY (Icelandic-Swedish-
S· development in above-knee socket 21 . Redhead RG: Total surface bearing self New York University) flexible above-
p design, in Donovan R, Pritham C, Wil- suspending above-knee sockets. knee socket. Phys Ther 1985;65:742.
son AB Jr (eds): Report of lSPO Work- Prosthet Orthot Int 1979;3: 126-136.
27. Kristinsson 0 : Flexible sockets and
W· shops, International Workshop on Above- 22. Pritham CH: Biomechanics and shape
more, in Donovan R, Pritham C, Wil-
·si- Knee Fitting and Alignment. of the above-knee socket considered in
son AB Jr (eds): Report of ISPO Work-
les, Copenhagen, Denmark, International light of the ischial containment con-
shops, international Workshop on Above-
>S· Society for Prosthetics and Orthotics, cept. Prosthet Orthot Int 1990;14:9-21.
Knee Fitting and Alignment.
'P 1987, pp 2-3. 23. Hoyt C, Littig D, Lunde J, Staats TB:
Copenhagen, Denmark, International
18. Hall CB: Prosthetic socket shape as The UCLA CAT-CAM Above-Knee Pros-
Society for Prosthetics and Orthotics,
)Ve- related to anatomy in lower extrem ity thesis, ed 3. Los Angeles, CA, UCLA
1987, pp 15- 19.
[): amputees. Clin Orthop 1964;37:32-46. Prosthetics Education and Research
Program, 1987. 28. Pritham CH, Fillauer C, Fillauer K:
l· 19. Radcliffe CW: Comments on new c,on- Experience with the Scandinavian
0, cepts for above-knee sockets, in Dono- 24. Kristinsson 0: Flexible above-knee
Flexible Socket. Orthot Prosthet 1985;
van R, Pritham C, Wilson AB Jr (eds): socket made from low density poly-
39:17-32.
Report of ISPO Workshops, International ethylene suspended by a weigh t trans-
mitting frame. Ortl'IOt Prosthet 1983;37: 29. Schuch CM: Thermoplastic applica-
Workshop on Above-Knee Fitting and
25-27. tions in lower extremity prosthetics.
iO. Alignment. Copenhagen, Denmark,
International Society for Prosthetics 25. Berger N: The ISNY (Icelandic- J Prosthet Ortl'IOt 1990;3: 1-8.
~c-
thet and Orthotics, 1987, pp 31-37. Swedish-New York) flexi ble above-
HD:
11
Surg
shop
1ee
eport
Nork-
ign-
Den-
: fit-
•o
gand
)rthot
1a-
fitting
ion of
ns:
975;
align-
hesis.

Hip Disarticulation and
Transpelvic Amputation:
Surgical Management
Howard A. Chansky, MD
Introduction
Hip disarticulation is the surgicaJ re- then referral to a regional center proximal levels. This often arises in
moval of the lower limb through the skilled in the surgical and postopera- patients with wet gangrene who are
hip joint. Transpelvic amputation tive management of these proximal also debilitated from underlying dis-
(hemipelvectomy) is the removal of amputations should be considered. ease, typically diabetes mellitus and
the entire lower limb in addition to severe vascular disease. Often these
most of the pelvis. Although 85% of patients will exhibit profound sys-
amputations are performed through
Causal Conditions temic signs of sepsis although the pe-
the lower Emb, few occur through the Although most hip disarticulations ripheral white blood cell count may
hip joint or pelvis. Nevertheless. the are performed to treat the sequelae of be normal. Necrotizing fasciitis is an-
surgeon should become familiar with peripheral vascular disease, trauma, other condition in which emergent
these high-level procedures as they and soft-tissue infections, most radical debridement or an1putation
are occasionally performed urgently transpelvic amputations are under-
may avert loss of life that occurs in up
for life-threatening infection or, taken to treat malignancies of the pel-
to 50% of cases.6•9
rarely, for life-threatening hemor- vis. 1.2 Even so, with tlle integration of
Many studies have documented tlle
rhage in the case of massive pelvic adjuvant radiation tllerapy and che-
inverse relationship between the level
trauma. In addition, elective amputa- motllerapy, advanced imaging tech-
of amputation and functional out-
tions through the hip or pelvis are niques and improved surgery have
resulted in tlle ability to use Emb- come. This is particularly true for pa-
sometimes needed for the treatment tients undergoing amputation for is-
of vascular disease, chronic infection sparing procedures for many malig-
nancies with local control rates equiv- chemia, infection, and systemic
witl1 soft-tissue loss, and malignan-
alent to those of amputation. disease as opposed to those often
cies. In addition, congenital limb defi-
Similarly, a multidisciplinary ap- younger and healthier patients who
ciencies are sometimes best treated by
proach to the care of those with para- are being treated for trauma or tumor.
conversion to a hip disarticulation.
plegia, vascular disease, or diabetes The need for tllese proximal ablations
This chapter reviews the technical
mellitus has lessened the need for ab- will most likely arise in patients who
aspects of hip disarticulation and
transpelvic amputation. Surgical indi- lative procedures to treat these condi- are bedridden or wheelchair bound
cations as well as perioperative ca1·e tions.3'4 A mangled limb secondary to because of paraplegia, previous ampu-
are also discussed. Hip disarticulation trauma remains an infrequent indica- tation at a lower level, advanced is-
and transpelvic amputation can be tion for hip disarticulation. Fortu- chemic disease, infection, or otller sys-
technically demanding procedures nately, transpelvic amputation to con- temic conditions. These patients are
with the potential for catastrophic trol massive bleeding due to trauma is more likely to have lesions requiring
blood loss and injury to pelvic vis- needed only rarely. 5 proximal amputation but, fortunately,
cera. Although a surgeon will rarely are less likely to have high functional
perform these procedures, he or she dema11ds. Nevertl1eless, these proce-
Indications and dures are quite disfiguring a11d should
should be versed in their technical
and medical aspects. If the surgeon is Contraindications not be undertaken lightly, regardless
unfamiliar with these techniques, and Preservation of life is tlle ultimate in- of the patient's preoperative func-
the patient can be safely transferred, dication for amputation at these tional status.

Indications for transpelvic ampu- and s

tation include malignant tumors, se- gical
vere infections, and the treatment of situat
extensive decubitus ulcers. Transpelvic be co
amputation is a disfiguring procedure Pa
that historically was the standard trans
technique to remove sarcomas arising sive
in and about the pelvis. The ability usual
to achieve clear margins with a rnorl:
transpelvic amputation is offset by the ative
ftmctional impairment reSlllting from these
removing the entire leg, hemipelvis, debri
and, often, part of the sacrum. have
Most sarcomas that arise in the pel- leagi;
vis spare vital structures such as the phys
pelvic viscera and iliac vessels and are tient
Figure 2 This patient has a soft-tissue thus amenable to treatment with neo- may
sarcoma of the adductor compartment. adjuvant therapy and limb-sparing its o:
The longit udinal incision is properly ori- surgery. To be successful, limb-sparing fects
ented, but the wide closure will requ ire protocols should yield a reasonably
excision at the definitive procedure. Care-
heali
functional limb and tumor-free sur- and
fu l subcuticular closure is optimal. (Re-
Figure 1 A transverse biopsy incision in produced with permission from Lawrence vival equivalent to that expected from m orl
the upper or lower limb severely compro- W Jr, Neifeld JP, Terz JJ: Diagnosis and amputation. For recmrent pelvic or tiom
mises attempts at limb salvage or distal staging of the soft-tissue sarcomas, in hip tumors, limb-sparing resection this
amputation. (Reproduced with permis- Egdahl RH (ed): Manual of Soft-Tissue Tu- should be undertaken only when wide
sion from Lawrence W Jr, Neifeld JP, Terz mor Surgery. New York, NY, Springer- patit
11: Diagnosis and staging of the soft- Verlag, 1983, p 28.)
surgical margins can be achieved. In- cal c
tissue sarcomas, in Egdahl RH (ed): Man- volvement of pelvic viscera or the sci- unre
ual of Soft-Tissue Tumor Surgery. New atic nerve or extension of tumor to the succ
York, NY, Springer-Verlag, 1983, p 28.) sacral neural foramina is generally the J
The importance of a carefully considered a contraindication to
planned biopsy of potentially malig- limb-sparing surgery. Other contrain-
Hip disarticulation for treatment nant lesions in the thigh and pelvic dications are lim ited life expectancy or Pr4
of a malignancy is performed less area cannot be overstated. A poorly an inability to rehabilitate after lirnb- The
commonly than transpelvic amputa- performed biopsy can lead to con- sparing surgery. trait
tion, limb-sparing procedures, or tamination of adjacent uninvolved Fortunately, the indications for surg
transfemora1 amputation. Nonethe- tissues and can compromise or pre- transpelvic amputation are decreasing putt
less, several clear indications exist fo r vent possible limb salvage or lead to a with advances in imaging and multi- app
hip disarticulation when managing more proximal amputation than modality preoperative adjuvant ther- the
lower limb malignancy. These include might have been initially possible. apy. Similarly, aggressive multidisci- ti.on
soft-tissue sarcomas intimately involv- Generally, biopsy incisions in the plinary management of pressure sores miz
ing the proximal sciatic nerve or fem - thigh should be longitudinal and in associated with paraplegia, diabetes cinE
oral a rtery as well as distal femoral mellitus, and vascular disease has re- mel
line with the eventual incision for de-
osteosarcoma with proximal in- sulted in improved outcomes and pre:
finitive surgery, and only one ana-
fewer transpelvic amputations. Soft- wit)
tramedullary skip lesions or patho- tomic compartment should be vio-
tissue sarcomas that involve the pelvic obt,
logic fracture through a proximal lated if possible. Also, prevention of
viscera, the iliac vessels or the femoral of
femoral osteosarcoma. Failed trans- postoperative hematoma with careful vessels in the region of the inguinal Ire;
femoral amputation or progressive, bemostasis is critical to prevent local ligament, and the bony pelvis may bio
li fe-threatening infection may also re- dissemination of tumor cells. Inci- still require a radical amputation to tive
quire hip disarticulation. Finally, sions in the pelvis are usually oblique achieve wide or even marginal mar- pro
childhood sarcomas adjacent to the or transverse but always in line with gins. Extensive loss of soft tissue and cul1
proximal femoral epiphysis may be the eventual incisions for either sal- disseminated osteomyel itis of the pel- all)'
best treated with hip disarticulation if vage or amputation. Figure 1 illus- vis may also necessitate transpelvic dee
dramatic limb-length discrepancies trates a poorly executed biopsy inci- amputation. In exh·eme cases, exten- be,e
wiJl result from attempts at limb sal- sion, and Figure 2 illustrates a more sive involvement of the soft tissues rati
vage. carefully planned incision. and the anticipated location of flaps as

Chapter 44: Hip Disarticulation and Transpelvic Amputation: Surgical Management 559
pu- and suture lines may necessitate sur- surface and deep cultures. 10 These in- removal of all diseased tissue while
se- gical diversion of the rectum. In these fectio ns are often polymicrobial, and leaving adequate soft tissue for pri-
t of situations, a general surgeon should adjustment of the dose, interval, and mary closure. Determination of the
lvic be consulted. duration of multiple antibiotics is of- extent of osteomyelitis or malignancy
lure Patients who are candidates for ten complicated by renal insuffi- has been improved by the combined
lard transpelvic amputation to treat exten- ciency. Determination of appropriate use of plain radiography and other
sing sive decubitis ulcers and infection antibiotics, monitoring of aminogly- advanced imaging studies. However,
ility usually have significant medical co- coside or vancomycin levels, and especially for in fection, no ideal single
11 a morbidities tllat jeopardize intraoper- checking for signs of ototoxicity and study exists that can perfectly delin-
rthe ative and postoperative survival. With nephrotoxicity can be done by the in- eate the extent of bone involvement.
rom these patients, previous attempts at fectio us disease specialist. A three-phase technetium Tc 99m
:lvis, debridement and soft-tissue coverage In my experience, the specialist in bone scan is supplemented at some
have often failed. Reliance upon col- rehabilitation medicine is often most institutions by an indium-111-
pel- leagues from internal medicine and helpful when predicting tlle potential labeled white blood cell scan. These
; the physiatry before treating such pa- for functional recovery after surgery. studies assist in the differen tiation of
:l are tients is critical, but these colleagues When tl1e expected functional out- soft-tissue infection from osteomyeli-
neo- may lack full appreciation of the 1im- come is more precisely defined, the tis, but poor spatial resolution contin-
aring its of surgical technology and the ef- threshold for undertaking more com- ues to limit their value when deter-
aring fects of systemic disease on wow1d plex tissue-sparing procedures may be mining surgical margins in pelvic
11ably healing and tolerance of anesthesia lowered. For example, a patient ex- infections. Plain radiography cannot
sur- and major surgery. These medical co- pected to be confined to a bed post- be used to detect early osteomyelitis
from morbidities are usually contraindica- operatively will not benefit from a with any reliability. CT is more sensi-
ic or tions to transpelvic amputation and more complex procedure with a tive to the presence of sequestra, loss
:ction this must be discussed frankly with greater risk of complications that is of trabeculae, and cortical erosion.
.wide patients, family members, and medi- designed to preserve bone stock and MRI provides detailed multi.planar
d. In- cal colleagues-all of whom may have soft tissue to enhance sitting balance. anatomic information about both
Le SCl- unreasonable expectations of sm·gical The physiatrist may also assist in cus- bone and soft tissue. T he sensitivity of
tO tlJe success and a tendency to minimize tomizing prostheses and wheelchairs MRI is reported to be greater than
terally the risk of serious complications. and choosing the appropriate facility 90%, and its specificity ranges from
n to for postoperative rehabilitation. 75% to greater than 90%.11 The reac-
1train- Preservation of tissue and determ i- tive marrow changes seen on MRI
ncy or Preoperative Care nation of the level of amputation is scans can sometimes be difficult to
limb- The orthopaedic surgeon is uniquely often best accomplished in consulta- distinguish from osteomyelitis.
trained to coordinate the medical, tion with both vascular and plastic The classification system initially
lS for surgical, and prosthetic needs of am- surgeons. An orthopaedic surgeon described by Enneking and Dun-
:easing putees. However, a multidisciplinary usually performs a hip disarticula- ham 12 to aid in the resection of pelvic
multi- approach is often critical in caring for tion, whereas a hemipelvectomy is of- sarcomas also has some use when
t ther- the amputee. The preoperative condi- ten performed in conjunction with a conceptualizing tl1e treatmen t of pel-
tidisci- tion of the patient should be opti- general surgeon. Other consultants, vic infection and soft-tissue necrosis.
·e sores mized by specialists in internal medi- including wound care specialists a nd Pelvic tumor resections with preser-
.iabetes cine. Because management of diabetes social workers, may also play impor- vation of the limb are divided into
has re- mellitus is often more difficult in the tant roles in optim izing the postoper- three types. Type I refers to resection
es and presence of an infection, consultation ative care of these patients. of the iliac region, type II is resection
;. Soft- with an endocrinologist should be of the periacetabular region, and type
e pelvic obtained to assist in the management III involves resection of the ischiopu-
femoral of brittle diabetes or ketoacid osis. Level of Amputation bis. The Roman numerals can be
nguinal Treatment with broad-spectrum anti- Once the decision has been made to combined to signify resection of m ul-
ris may biotics can be instituted preopera- perform a transpelvic amputation, the tiple regions; for exam ple, type II/
ttion to tively, ideally after obtaining ap- surgeon must decide how much of type III resection.
al mar- propriate cultures. lntraoperative the hemipelvis and possibly the Many patients undergoing ablative
sue and cultures are important, as this is usu- sacrum to remove. The level of the surgery for pelvic infection and soft-
the pel- ally the best opportuni ty to secure bony resection within the pelvis is de- tissue loss are paraplegic, but situa-
nspelvic deep cultures tlu-ough skin that has termined primarily by disease man- tions arise when either the limb
;, exten- been sterilized d uring surgical prepa- agement and much less by m inor po- should be spared or amputation is
: tissues ration . Deep cultures are important, tential functional differences. Every performed in such a way as to remove
cif flaps as there is poor correlation between attempt should be made to ensure the the obturator ring and preserve the

560 Section ITI: The Lower Limb
A.r
Figu1
cisio1
t ran:
Sugc
eta I
dem
Figure 3 A 45-year-old man with longstanding paraplegia, severe pelvic osteomyelitis, and skin loss. A, The patient required frequent
blood transfusions because of the erosive nature of t his exposed bone and soft t issue. In previous operations, he had undergone trans-
fer of all local rotation flaps. The only coverage available for transpelvic amputation was the thigh and calf f illet flap. B, Radiograph of imp
the pelvis shows osteomyelitis and heterotopic bone formation. C, Following colostomy, a radica l procedure was planned to remove abd
the bony hemipelvis and all involved soft tissue but w ith preservation of the thigh and calf soft tissue for closure. The f illet flap is il-
lustrated before rotation and closure. D, The flap was rotated and contoured to wrap over the sacrum, the ischium, and the defect
preJ
from t he hemipelvis resection. drai
sior
sup
nea
ischial tuberosity. [n addition, when Surgical Technique Hip Disarticulation gui
other adequate local flaps are not pro
Fortunately, a large, muscular soft- The standard technique for hip disar-
available, a thigh or calf fillet flap can tub
tissue envelope surrounds the pelvis ticulation is based on the procedure
be used to treat end-stage extensive pos
and thigh. This permits a variety of described by Boyd. 15 This procedure
pressure sores involving the pelvis tin1
incisions and flaps to work around uses a racquet incision to create a du-
(Figure 3). This procedure entails re- the
quite extensive areas of skin necrosis rable posterior flap. Slocum 16 im-
section of the involved pelvis, sacrum, ta]
and infection. The techniques de- proved upon the initial technique by
femur, and tibia with filleting of the scribed here are based on generally rur
recommending a longer posterior flap
leg to provide a long, vascularized accepted principles and anatomic to avoid weight bearing on the suture thi
soft-tissue flap for reconstruction of approaches, but at times, tissue re- line (Figure 4). He also recommended inc
the buttock and sacral areas. 13 • 14 As quired for reconstruction and closure dividing the sciatic, femoral, and ob·
much of the bony pelvis is sacrificed of the amputation site is not avail- turator nerves as proximally as neces- to
as necessary. The goals of this proce- able because of disease extent. Espe- sary to minimize irritation of the fer.
dure are to remove infected bone and cially for cases involving malignant neuromas. For posterior decubitis ul- cis
soft tissues, bony prominences that tumors, severe trauma, or necrotizing cers or tumors, an anterior flap based ter
may result in postoperative break- fasciitis, the surgeon may need to on the rectus muscles and femoral ar- Th
down, and any bone necessary to re- individualize the surgical approach tery can be used. is
duce the area needing soft-tissue cov- and the reconstructive plan based on The patient is placed in a lateral ep
erage. Cosmetic appearance can be what tissues are salvageable. In these decubitis or semisupine position on a ral
enhanced by retention of the ileum. types of situations, considerable sur- beanbag with loose support that will lig
Sitting balance can be partially spared gical ingenuity may be required to allow 20° to 30° of both anterior and in,
by preserving the ischial tuberosity. acheive a satisfactory result. posterior additional mobilization to re,

Ch apter 44: Hip Disarticulation and Tran spelvic Amputation: Surgical Management 561
teus medius and minimus muscles, as

well as the external rotators, including
.,
I J•
the obturator externus, are detached
at their insertions onto the greater
trochanter. The sciatic nerve is di-
vided at its exit from the sciatic notch
Greater trochanter
and ligated; the nerve may be injected
Anterior inferior iliac spine with bupivacaine to enhance postop-
erative analgesia. Finally, the ham-
Anterior superior iliac spine
strings are divided from their origins
on the ischial tuberosity. The incision
of the posterior hip capsule completes
the amputation.
lschial tuberosity The quadratus femoris and ilio-
psoas muscles can be approximated to
cover and fill the dead space and the
acetabulum. A saw and rasp can be
used to smooth and lower the profile
of the acetabular lip if this should be
too prominent. Next, the obturator
Figure 4 The typical racquet-shaped incision that is used for hip disarticulation. The in- externus and gluteus medius muscles
cision is centered over the femora l triangle, and the femoral vessels are ligated and are sutured together over the acetabu-
transected early in the procedure. (Reproduced with permission from Malawer MM,
Sugarbaker PH: Hip disarticulations, in Malawer MM, Sugarbaker PH (eds): Musculoskel-
Jum. Another alternative is to suture
etal Cancer Surgery: Treatment of Sarcomas and Allied Diseases. Boston, Kluwer Aca- the stumps of the gluteus medius and
demic Publishers, 2001, p 340.) minimus muscles to the free origins
'requent of the adductor muscles. T he gluteus
1e trans- maximus fascia is placed over suction
graph of improve visualization as needed. The from the anterior superior iliac spine
drains and anchored to the inguinal
, remove abdomen, groin, buttock, and leg are and anterior inferior iliac spine re- ligament and pubic ramus with a
flap is il- prepared for surgery, and the leg is spectively. The hip is flexed, and blunt nonabsorbable suture. The skin .is
,e defect draped free. The racquet-shaped inci- dissection with a tinger aided by an closed beneath a soft compressive
sion begins just medial to the anterior elevator is used to get around the il- dressing.
superior iliac spine and descends iopsoas muscle just proximal to its in- Hip disarticulation is better toler-
nearly parallel and inferior to the insertion into the lesser trochanter. The ated than transpelvic amputation,
guinal ligament down to a point ap- psoas is divided at its insertion. The with wow1d complications being less
proximately 5 cm distal to the ischial plane between the pectineus and ob- frequent and potential for recovery of
1ip disar-
,rocedure tuberosity and gluteal crease. The turator externus muscles is identified, ftmction and use of a hip disarticula-
posterior portion of the incision con- and the pectineus muscle is divided at tion prosthesis much greater. Never-
,rocedure
:ate a du- tinues parallel to the gluteal crease, its origin from the pubis. The obtura- theless, the complication rate remains
Lffi16 im- then curves anteriorly about 8 cm dis- tor extemus is transected at its inser- significant, and mortality may actu-
mique by tal to the greater trochanter, and then tion on the femur as opposed to its ally be higher than with transpelvic
terior flap runs obliquely across the anterior origin to avoid accidental division of amputation; this is likely related to
tbe suture thigh to meet the apex of the original the obturator artery and its retraction the fact that most patients undergo-
mmended incision. into the pelvis. The origins of the gra- ing this procedure have severe vascu-
l, and ob- Medial and lateral flaps are created cilis, adductor longus, adductor lar disease and coronary artery dis-
{ as neces- to expose the inguinal region and brevis, and adductor magnus muscles ease. 17
>n of the femoral triangle. Scarpa's fascia is in- are divided with the electrocautery Several modifications of the stan-
:cubitis ul- cised, and the aponeurosis of the ex- while the leg is held in extension and dard hip disarticulation have been de-
flap based ternal oblique muscle is visualized. abduction. To complete the anterior scribed. One recent modification is a
18
femoral ar- The spermatic cord (round ligament) portion of the procedure, the hip cap- laterally based approach. The ap-
is retracted medially. The superficial sule is incised, and the ligamentum proach is more familiar to most or-
,n a lateral epigastric vessel is ligated. The femo- teres is divided with electrocautery. thopaedic surgeons, and dissection of
ral vessels and the femoral nerve are The thigh is rotated internally, and major blood vessels is easier, resulting
>Sition on a
,rt that will ligated at their exit from beneath the the tensor fascia lata and gluteus in less blood loss. In addition, an an-
inguinal ligament. The sartorius and maximus muscles are divided in line terior rectus femoris flap can be con-
nterior and
rectus femoris muscles are detached with the skin incision. Next, the glu- structed in patients with posterior tu-
,iliza tion to

facilitating dissection. With the h ip from within the retroperitonea] space.

Posterior
incision adducted and flexed, the perinea! and At this point, division of the psoas
posterior portions of the amputation m uscle and obturator nerve may fa.
can be performed. Enemas are used to cilitate access to the common iliac
empty th e large bowel preoperatively. and iliolumbar vessels. The external
A Foley catheter is placed; the ipsilat- iliac vessels and the femoral nerve are
eral leg is d raped free; and the skin of divided and ligated. In the case of tu-
nerve the abdomen, groin, buttock, abdo- mors, the vessels may need to be di-
men, perineum, and leg is prepared vided through the common iliacs. As
for surgery. For tumor resection or the dissection proceeds posteriorly
Common complex cases of infection, a stent along the pelvis, the iliolumbar, lat-
femoral
artery and vein placed in the ipsilateral ureter at the eral sacral, superior and inferior glu-
beginning of the procedure may aid teal, and internal pudenda! branches
in safe dissection, especially after pre- of the internal iliac artery are divided.
vious surgery or irradiation. The At this point, the lumbosacral plexus
scrotum may be stitched to the oppo- and hypogastric vessels should be free
site thigh to aid in retraction. The to retract medially.
Figur
an us can be sutured or sealed with an The incision for the posterior por- ment
impermeable dressing. If the tumor tion of the procedure passes either di- the I:
or infection does not involve the pos- rectly down the anterior border of the sion
Figure 5 The utilitarian incision for pelvic terior soft tissues, a standard poste- greater trochanter or anteriorly to- come
resect ion or t ranspelvic amputation be- rior flap is used. If the buttock mus- Verla
ward the trochanter and then down
gins at the pubic tubercl e and extends
along t he inguinal ligament and the iliac
cles are involved, an anterior flap the leg, depending on how far the in-
crest. Depending on t he surgeon's prefer- based o n the rectus femoris is used. cision was carried posteriorly. The hip the •
ence, t he incision is directed inferiorly The standard posterior flap for is sharply flexed and the incision is der
somewhere between the anterior supe- transpelvic amputation proceeds continued several centimeters distal
rior iliac spine and t he posterior superior
able
from the anterior dissection, designed and parallel to the gluteal crease. The divi<
iliac spine. For transpelvic amputation,
the incision is extended posteriorly be-
to mobilize the parietal peritoneum larger the anterior-posterior diameter
striJ
hind the thigh and t hen along t he infe- and isolate the iliac vessels, to the of the pelvis, the more distal this inci- mus
rior pubic ramus to t he pubic tubercle. posterior and perinea! portions.20•21 sion should be made. Mobilization of is cc
(Reproduced with permission from The incision begins at the pubic tu- the intestines with exposure of the
Malawer MM, Sugarbaker PH: Overview ity t
bercle and extends along the inguinal retroperitoneum often leads to an il-
of pelvic resections: Surgical consider- cocc
ations and classifications, in Mala wer ligament and the iliac crest. Depend- eus. This can result in additional
as
MM, Sugarbaker PH (eds): Musculoskele- ing on the surgeon's preference, the stress on the closure so the length of
sacr
t al Cancer Surgery: Treatment of Sarco- incision is directed inferiorly some- the flaps should be approp riately gen-
mas and Allied Diseases. Boston, Kluwer mar
where between the anterior superior erous. For tumor cases, the posterior
Academic Publishers, 2001, p 213.) fron
iliac spine and the posterior superior flap often consists solely of the skin
and
iliac spine (Figure 5). The most poste- and su bcutaneous tissues; the gluteus
of I
mors or soft-tissue necrosis. Frey and rior ei..'tent of the incision is not nec- maximus may be preserved in pa-
are
associates19 described the use of this essary unless the sacrum is involved, tients with nontumorous conditions.
but the additional length affords eas- the
femoral artery-based flap in trans- In this case, the aponeurosis of the
ier access to the posterior dissection. gluteus maximus m uscle is d ivided at mer
pelvic amputations, but it can also be the1
T he anterior portion of the standard its posterior and inferior edges.
used for hip disarticulation . or t
transpelvic amputation proceeds by The flap is retracted upward and
dividing the insertion of the rectus elevated over the iliac crest and rior
Transpelvic abdominus muscle and detachment sacrum; the piriformis muscle and saw
of the inguinal ligament and abdomi- sciatic nerve are divided. The paraspi- Clo
Amputation fast
nal muscles from the iliac crest. Un- nal muscles of the back m ust also be
The standard transpelvic amputation roofo1g the inguinal canal exposes the subperiosteally stripped from the dra
is performed with the patient posi- iliac vessels, the retropubic space, and posterior crest. For the perinea] por- pla,
tioned midway between the supine the spermatic cord (round ligament) . tion of the amputation, the limb is 14 ,
and the lateral decubitus position. The bladder is retracted posteriorly wid ely abducted by an assistant or
This permits the pelvic viscera to away from the pubis. The inferior epi- suspended from a traction apparatus. the
move away from the ipsilateral pelvis, gastric vessels are divided and ligated. The incision is continued from the ton
allowing easy surgical access to the T he internal iliac vessels, meter, and pubic tubercle or symphysis down tun
anterior portion of the incision, thus lurnbosacral trunk are dissected free along the pubic and ischial rami to enc

Chapter 44: Hip Disarticulation and Transpelvic Amputation: Surgical Management 563
guinal incision, with an extension

ce. lliotibial tract
)as down tl1e anterolateral thigh and even
Vastus lateralis the leg as needed. Depending upon
fa-
.1ac Rectus lemoris how far posterior or anterior across
nal the mid.line this incision is carried,
are the entire internal and external bony
tu- pelvis can be exposed. An internal
di- hemipelvectomy with a fillet flap ex-
As tending nearly down to the ipsilateral
>rly ankle ca11 be used to provide soft-
lat- tissue coverage of severe sacral and
~lu- bilateral trochanteric decubitis ulcers.
:hes Because these procedures often re-
led. Adductor longus
sult in the creation of substantial
:xus dead space, suction drains should be
Vastus medialis Superficial femoral artery and vein
free used liberally and be sutured into
place to prevent accidental removal.
Figure 6 When posterior soft tissue is not available for coverage because of involve-
JOr- ment by tumor or necrosis, an anterior myocutaneous flap based on the quadriceps and Soft compressive dressings are applied
: di- the blood supply from the superficial f emoral artery is used. (Reproduced with permis- to encourage the different tissue
'the sion from Lawrence W Jr, Neifeld JP, Terz 11: Diagnosis and staging of the soft-tissue sar- planes to adhere, thus minimizing se-
comas, in Egdahl RH (ed): Manual of Soft-Tissue Tumor Surgery. New York, NY, Springer- roma and hematoma formation.
to-
Verlag, 1983, p 28.) Transpelvic amputation is chal-
own
! 111- lenging for tl1e surgical team and, of
: hip the ischial tuberosity. With the blad- these situations, an anterior myocuta- course, much more so for the patient.
,n is der and urethra protected by malle- neous flap may be used that includes Complications are frequent, occur-
listal able retractors, the pubic symphysis is aU or a portion of the quadriceps and ring in up to half 'of patients. 23
The divided. The corpus cavernosum is is based on blood flow from the su- Wound complications are common
1eter stripped from the inferior pubic ra- perficial femoral artery (Figure 6). regardless of surgical technique but
inci- mus. The division of the pelvic floor This flap can be as long as necessary are most common in those with a
m of is completed from the ischial tuberos- to obtain coverage posteriorly. In ad - subcutaneous flap. 24 Postoperative
' the ity to the coccyx, dividing the ischio- dition, the posterior coverage pro- death occurs in up to 6% of pa-
in il-
coccygeus and iliococcygeus muscles vided by the quadriceps muscle pro- tients.23 Rehabilitation is easiest for
ional as well as the sacrotuberous and vides a durable cushion upon which those with an internal hemipelvec-
th of the pateint may sit in a weight- tomy with preservation of the sciatic
sacrospinal ligaments. During these
gen- bearing prosthesis. nerve. For those with a standard
maneuvers, the rectum is mobilized
erior There is a clinical role for what is transpelvic amputation, prostheses
from the muscles of the pelvic floor
skin referred to as a modified transpelvic are mainly for cosmesis as they are
and protected. Returning to the inside
uteus amputation (modified hemipelvec- heavy and provide only partial
of the pelvis, the sacral nerve roots
I pa- weight-bearing support. About one
are transected and ligated lateral to tomy ). Preservation of the acetabu-
tiOUS.
lum and ischium will result in the half of younger patients prefer to use
the foramina. The iliolumbar l iga-
f the a prosthesis. For many patients,
ment is also divided. A Gigli saw is best functional resu lt with respect to
led at crutch walking may actually be easier
then passed through the sciatic notch sitting balance, and salvaging the iliac
without the added weight of a pros-
or the sacroiliac joint, and the poste- wing will allow for better suspension
and thesis. 25 Special adaptive pillows can
rior pelvis is divided. An oscillating of a prosthesis and improved cosme-
and be fash ioned to make sitting more
saw may also be used for this step. sis.
and comfortable.
Closure is performed in a standard Internal hemipelvectomy is used
raspi-
fashion over multiple large suction for treatment of bone tumors but is
lso be
I the drains. Sutures may need to be left in occasionally used for soft-tissue sar- Immediate
place longer than the standard 10 to comas and extensive pressure sores Postoperative
1 por-
14 days. and infection. It is the technique per-
mb is Management
int or Occasionally, tissues tl1at comprise formed when the bony pelvis and the
tratus. the standard posterior hemipelvec- bones of the leg are excised in the If an ileus develops, insertion of a na-
m the tomy flap may be contaminated by construction of a fillet flap. 13·22 An sogastric tube should be considered
down tumor or compromised by the pres- internal hemipelvectomy is usually u1 most cases. A general rule is to re-
uni to ence of ulceration and necrosis. In done through an extended ilioin- move the suction drains when the

output is less than 100 mL per day. experience. Arch Surg 1990;125: lower leg flap. Plast Reconstr Surg 1997;
Antibiotics are contim1ed at least w1- 791-793. 99:1439-144L.
til the drains are removed, with the 3. Larsson ), Apelqvist ), Agardh CD, 15. Boyd HB: Anatomic disarticulation of
ultimate duration decided in con- Stenstrom A: Decreasing incidence of the hip. Surg Gynecol Obstet 1947;84:
major amputation in diabetic patients: 346-349.
junction with the infectious disease
A consequence of a multidisciplinary
servke. For prophylaxis against deep 16. Slocum DB: Atlas of Amputations. St
foot care team approach? Diabet Med
vein thromboses, at the U niversity of Lou is, MO, Mosby, 1949.
l 995;12:770-776.
Washington we typically use low- 17. Endean ED, Schwarcz TH, Barker DE,
4. Valdes AM, Angderson C, Giner JJ: A
molecular-weight h eparin and me- Mu nfakh NA, Wilson-Neely R, Hyde
multid isciplimry, therapy-based, team
GL: Hip disar ticulation: Factors affect-
chanical measures such as a foot approach for efficient and effective
wou nd healing: A retrospective study. ing outcome. J Vase Surg 1991;l 4:
pump or pneumatic sequential com-
Ostomy Wound Manage 1999;45:30-36. 398-404.
pression device on the contralateral
5. Smejkal R, Tzant T, Born C, Delong W, 18. Lackman RD, Quartararo LG, Farrell
leg. This regin1en is resumed or begun
Schwab W, Ross SE: Pelvic crush inju- ED, Scopp JM: Hip disarticulation
12 to 24 homs postoperatively but
ries with occlusion of the iliac a rtery. using the lateral approach: A new
should be stopped with any sign of technique. Clin Orthop 2001;392:
J Trauma 1988;28:1479-1482.
bleeding or hematoma formation . 372-376.
6. Brandt MM, Corpron C, Wahl WL: ln1
Necrotizing soft tissue infections: A 19. Frey C, Matthews LS, Benjamin H,
Summary surgical disease. Am Surg 2000;66:
967-971.
Fidler WJ: A new technique for hemi- For
pelv
pelvectomy. Surg Gynecol Obstet 1976;
Disarticulation of the hip and 7. Elliott DC, Kufera JA, Myers RA: Ne- 143:753-756. tion
transpelvic amputation are techni- crotizing soft t issue infections: Risk 20. King D. Steelquist J: TransiJiac ampu- chal
cally challenging procedures that re- factors for mortality and strategies for tation. J Bone Joint Surg Am 1943;25: diffi
quire careful planning to minimize management. Ann Surg 1996;224: 351-367. tire
672-683. ergy
the occurrence of intraoperative and 21. Sugarbaker PH, Chretien PB: Posterior
postoperative complications. In addi- 8. Francis KR, Larnaute HR, Davis JM, Aap hemipelvectomy, in Sugarbaker sud
Pizzi WF: Implications of r isk factors PH, Malawer MM (eds): Musculoskele-
tion, the broad spectrum of diseases as 11
in necrotizing fasciitis. Arn Surg 1993;
leading to the need for hip disarticu- tal Surgery for Cancer: Principles and buh
59:304-308.
lation or transpelvic amputation, and Techniques. New York, NY, Thieme the
9. Singh G, Sinha SK, Adhikary S, Babu Medical Publishers, 1992, pp 121-137.
the variable location of specific le- any
KS, Ray P, Khanna SK: Necrotizing
22. Lawton RL, De Pinto V: Bilateral hip con
sions, m ay demand a creative ap- infections of soft tissues: A clinical
disarticulation in paraplegics with by I
proach to develop adequate soft- profile. Eur J Surg 2002;168:366-37 1.
decubitus ulcers. Arch Surg 1987;122: ma1
tissue flaps. The patient is best served 10. Sharp CS, Bessman AN, Wagner FW
1040-1043.
by a multidisciplinary team, including Jr, Garland D: Microbiology of deep
23. Apffelstaedt JP, Driscoll DL, Spellman dis,
surgeons, internists, physiatrists, t issue in diabetic gangrene. Diabetes
Care 1978; 1:289-292. JE, Velez AF, Gibbs JF, Karakousis CP: teei
physical and occupational therapists, Complications and outcome of exter-
11. Unger E, Moldofsky P, Gatenby R, not
and prosthetists. Despite these efforts, nal hemipelvectomy in the manage- the
Hartz W, Broder G: Diagnosis of
the potential for fu nctional reha bilita- ment of pelvic tumors. Ann Surg Oneal anc
osteomyelitis by MR imaging. A]R
tion following these procedures may 1996;3:304-309.
Am J Roentgenol 1988; 150:605-610. hig
be lim ited. 12. Enneking WF, Dunham WK: Resec- 24. Capanna R, Manfrini M, Pignatti G, pr<
tion and reconstruction for primary Martelli C, Gamberini G, Campanacci pat
neoplasms involving the innominate M: Hemipelvectomy in malignant Ste :
References bone. J Bone Joint Surg Am 1978;60: neoplasms of the hip region. Ital J d~
L. Hierton T, James U: Lower extremity 731-746. O,thop Traumatol 1990;16:425-437.
wiJ
amputation in Uppsala county 1947- 13. Strinden WD, MiJcter RC, Dibbell DG 25. Sneppen 0, Johansen T, Heerfordt J, twc
1969: Incidence and prosthetic reha- Sr: Internal hemipelvec tomy as a treat- Dissing I, Petersen 0: Hemipelvec- art
bilitation. Acta Orthop Scand 1973;44: ment for end-stage pressure sores. Ann tomy: Postoperative rehabilitation
573-582.
es1
Plast Surg 1989;22:529-532. assessed on the basis of 41 cases. Acta
age
2. Unruh T, Fisher DF Jr, Unruh TA, 14. Yamamoto Y, Minakawa H, Takeda N: Orthop Scand 1978;49:175-179.
et al: Hip disarticulation: An 11-year Pelvic reconstruction with a free fillet
pu
hii
m1
ha
fit
di:

997;
n of Hip Disarticulation and

i4:
Transpelvic Amputation:
5t
DE,
•de Kevin M. Carroll, MS, CP
ffect-
rell
Introduction
I,
emi- For hip disarticulation and trans- vide sufficient foundation to achieve a even though there is no bony struc-
976; pelvic amputees, the path to func- positive result. With proper attention ture on the involved side of these am-
tional prosthesis use can be Jong and to details in material selection and putations.
npu- challenging because of the inherent socket configuration, the fitting and In 1957, Radcliffe 7 presented a bio-
;25: difficulty of ambulation when the en- fabrication of a comfortable, func- mechanical analysis of the forces nec-
tire lower limb has been lost. The en- tional prosthesis can be achieved. essary for ambulation with the Cana-
;terior ergy requirements of prosthesis use in dian hip disarticulation prosthesis
ker such situations have been shown to be (Figure 3). This improved clinical un-
>skele- as much as twice that of normal am- Historical
ind bulation. l Historically, this level has Background
1e the highest incidence of rejection of The original tilting table prostheses of
.- 137. any lower limb prosthesis,2·3 with un-
the 1940s for hip disarticulation and
I hip comfortable sockets being mentioned
transpelvic amputees were not very
th by many amputees as one of the pri-
successful. These prostheses consisted
;122: mary reasons for rejection.
of a molded leather socket with a lat-
Prosthetists who work with hip
erally placed locking hjp joint (Figtue
llman disarticulation and transpelvic ampu-
is CP:
1); shoulder straps were often re-
tees face a task that is daunting but
exter- not impossible. They must educate quired for suspension. The tilting ta-
age- ble prosthesis always incorporated a
~Oncol
the patient about the unique design
and fitting requirements of these locking knee joint, and the combina- •
high-level sockets. Dw-ing the fitting tion of a locked hip and knee resulted
tiG, process, both the prosthetist and the in a very awkward and ungainly gait.
,anacci patient must be satisfied with s[ow, Canadian researcher Colin Mclau-
nt steady progress, remaining hopeful rin introduced the Canadian hip dis-
ill despite the inevitable frustrations that articulation prosthesis in 1954 (Fig-
437. will arise. Good communication be- ure 2). His design positioned the
rdt J, tween the prosthetist and the hip dis- amputee's center of gravity posterior
rec- articulation or transpelvic amputee is to the hip joint and anterior to the
LOn especially important to avoid discour- knee joint during weight bearing,
s.Ada using biomechanics to stabilize these
agement.
Not only is the fitting of these am- joints without locking them. 4 •5 Build-
putees difficult, but because these ing on this concept, Ly11quist6 pro-
high-level amputations are increas- posed a fitting concept for a Figure 1 The tilting table prosthesis had
a molded leather socket and a laterally
ingly w1common, most prosthetists Canadian-type plastic socket for a
placed locking hip j oint. The center of
have only limited personal experience transpelvic amputee, which proved to gravity was positioned right t hroug h t he
fitting these patients. The principles be effective for achieving comfortable prosthetic hip joint, making t he design
discussed in this chapter should pro- weight bearing via the soft tissues, inherently unstable.

adde
ity, (
the <
sits.
skele
ium
(Fig1
socki
and
uprii
tomi
sults
men
bene
equa
pare,
T
shap
enha
resul
Figure 3 Biomechanical analysis of the forces necessary for ambulation led to develop- infer
ment of the Canadian design, which demonstrated that locked joints were not neces- to tl
sary in hip disarticulation and transpelvic prostheses. (Reproduced with permission from keep
Radcliffe CW: The biomechanics of the Canadian-type hip-disarticu/ation prosthesis. out<
Artif Limbs 1957;4:29-38.)
lates
be a
tissu
Figure 2 Mclaurin's Canadian-style pros- providing factual information and en - tracture. Physical therapy is an im-
thesis was introduced in 1954. It demon- sock
couragement are key elements of the portant part of recovery for these am-
strated the feasibility of using unlocked suclti
prosthetist's role. The residual limb putees, and it is often useful to invite
hip, knee, and ankle joints that relied on amp
biomechanics to achieve stance-phase should be thoroughly palpated to as- a physical therapist to participate in
stability while permitting flex ion at the certain the remaining bony architec- the initial evaluation. Ma
hip and knee during swing phase. ture as well as pressure-tolerant and The
pressure-sensitive areas. Postoperative Socket Design and a lig
derstanding of McLaurin's recom- radiographs are helpful to refer to at such
mendations about alignment of these this stage. Because of the lack of pro-
Interface
that
prostheses. Michael 8 further analyzed tective pelvic bone in transpelvic am- The component that merges the user flexi'
and endorsed the alignment of the putees, the prosthetist must deter- with the prosthesis is the socket. 9 The are l
Canadian-type prosthesis in 1988, mine how to prevent the socket from fit of the socket is critical because it fiber
noting the potential advantage of putting excessive pressure on the determines the comfort and func- adds
fluid-controlled knee mechanisms bladder or kidneys. This is accom- tional capabilities of the prosthesis. porn
(Figure 4). McLaurin's alignment rec- plished by applying manual pressure Socket comfort is a major determi- be c
ommendations for hip disarticulation at various angles on the residual limb. nant of whether or not the user will the,
and transpelvic designs are now well The skin surface must be exami ned wear the prosthesis long-term. Many cord
accepted worldwide. carefully for adhered scar tissue and hip disarticulation and transpelvic shoe
skin grafting. Some patients will have amputees who have a negative experi- wou
a colostomy bag or a catheter, which ence with the initial fitting give up on caus
Patient Evaluation must be taken into consideration in wearing a prosthesis altogether and pros
The initial evaluation of a patient the design of the socket. T he patient is opt to live life on crutches. 10 nent
with a high-level amputation involves also examined carefully for compen- weig
a thorough physical examination. satory scoliosis and other postural ad- Design carb
This is an excellent opportunity to be- aptations that may influence align- Modern endoskeletal prosthetic hip cate,
gin building a good rapport and open ment of the prosthetic components. joints are typically placed somewhat
communication between the patient Upper body strength is evaluated. more distally on the socket than were ( 01
and the prosthetist. Listening to the The unaffected side is examined to the exoskeletal joints of McLaurin's Wei!
amputee's frustrations and goals and detect any hip or knee flexion coo - day (Figure 5, A). This often· results in vie 1

Chapter 45: Hip Disarticulation and Transpelvic Amputation: Prosthetic Management 567
added bulk under the isch ial tuberos-

ity, causing the socket to lean toward
the opposite side when the amputee
sits. It is possible to place the endo-
skeletal hip joint lateral to the isch-
ium and somewhat more proximally
(Figure 5, B). This minimizes the
socket thickness under the ischium
and allows the amputee to sit more
upright. This somewhat more ana-
tomic placement of the hip joint re-
sults in a slightly longer thigh seg-
ment than if the joint were placed
beneath the ischium, thereby better
equalizing the thigh-shin length com-
pared with the sound side.
The lateral socket contour can be
shaped to match the opposite side,
enhancing the cosmesis of the final
result. The socket includes a platform B
relop- inferior to the ischium that is parallel
1eces· to the ground in standing; this helps Figure 4 A, Canadian prosthesis in early sw ing phase. The hip joint remains neutral as
from keep the residual limb from slipping the shank swings forward. B, Canadian prosthesis just after midswing. The hip j oint does
thesis. not f lex until shank mot ion is arrest ed by the t erminal extension st op. As a result, t he
out of the socket as the patient ambu-
prosthesis is f ully extended at the instant of midswing, which makes toe clearance diffi-
lates. Suprailiac suspension can often cult. (Reproduced with permission from Michael J: Component selection criteria: Lower
be augmented by capturing the soft limb disarticulations. Clin Prosthet Orth ot 1988;12:99-108.)
tissues in an intimately contoured
1 im· socket, similar to the concept of a
eam- suction socket for the transfemoral fitting a socket for the transpelvic am- treme cases, this can result in rib
invite amputee. 11 ' 12 putee particularly challenging. The fractures.
ate in sound gluteus maximus should be Hip disarticulation sockets should
Materials captured within the socket as much as incorporate ischial containment,
The socket is commonly formed from possible, and the trimline kept as which prevents the t uberosity from
I a lightweight thermoplastic material close to the sound side as the patient slipping out of the socket and en-
such as polypropylene and copolymer can tolerate. Otherwise, the soft tis- hances control over the prosthetic
that is durable yet permits areas of sues tend to protrude distally under limb. Ischial containment stabilizes
1e user flexibility as needed. 13· 15 Most sockets weight bearing as the socket pistons the prosthesis in the coronal and sag-
t.9 The are positioned inside a rigid carbon- up and down on the patient's torso. ittal planes 1 1' 12 (Figure 7). The lower
ause it fiber-reinforced outer frame that This is sometimes referred to as an is- portion of the pubic ramus is also
func· adds stability and anchors the com- chial shelf on the sound side, 16 but it contained within the socket, and the
sthesis. ponents securely. The socket should is more likely peripheral weight bear- ascending portion exits the socket
!termi- be custom designed to accommodate ing on tl1e bulk of tlle gluteal muscu- along the medial trim line. A thin
;er will the weight of the individual user; ac- lature (Figure 6). piece of low-modulus material can be
. Many cordingly, a lighter weight person It is importan t to create a stable placed under the ischial tuberosity as
1spelvic should receive a lighter socket than and secure weight-bearing surface in a cushioning layer if necessary. If the
exl)eri· would a much heavier individual. Be- the socket, based on an accurate neg- ischiopubic ramus is not contained
e up on cause the primary weight of such ative plaster impression. When the without causing discomfort, the pa-
1er and prostheses derives from the compo- weight bearing is tenuous, controlling tient will likely reject the prosthesis.
nents rather tha11 the socket, light- the prosthesis is very difficult, creat-
weight materials such as titanium or ing a feeling of uncertainty that is
carbon composites are generally indi- more pronounced for tra nspelvic Casting, Fitting, and
~tic hip cated. amputees. When this occurs, patients
mewhat sometimes try to compensate by
Suspension
1an were Containment tightening the proximal portion of Casting
Laurin's Weight bearing in the absence of pel- the socket, increasing pressure di- The casting process for hip disaTticu-
esults in vic bone on the involved side makes rectly underneath the rib cage. In ex- lation and transpelvic sockets is very

Figure
teals ii
Figure 6 The gluteal ring on the unaf- fitting
fected side has been captured within this
completed transpelvic socket, giving the
A B user added stability and more even distri- above
bution of pressure. The u
Figure 5 A, Transpelvic prosthesis demonstrates an outset hip joint, evenly aligned hips
just p
and knees, and the upper edge of the socket locked around the iliac crest and soft tis-
sue. The dotted line on the unaffected limb identifies t he key area of socket contain- the sound hip above the iliac crest. It borde
ment, defined as the gluteal ring. The dotted line on the amputated side indicates the is important that the plaster mold ex- some
weight distribution area where the residual limb contacts the socket. B, Hip disarticula- occur:
tion prosthesis demonstrates ischial containment, the outset hip joint, evenly aligned
tend to the midline anteriorly and
posteriorly (Figure 8). Finally, the trans r
hips and knees, and the upper edge of the socket locked around the iliac crests.
casting apparatus is donned again and are ol
the anterior and posterior impression rior b
similar. The amputee dons a snug- casting process. This casting apparatus plates are cinched tightly into place, pa tier
fitting stockinette. If it has a vertical is fitted to the patient before any plas- contacting the cast directly and caus- sittini
seam, this is positioned at the midline ter is applied, and the tubing is ing a slight flattening of the plaster dure
of the body, in contact with the coccyx snugged over the ilium, particularly on (Figure 9). The hip joint placement mal a
and symphysis pubis. A simple device the sound side. The tubing allows for a can be identified at this time. small
fashioned from clear plastic and soft more accurate cast in this region, im- pa tier
tubing may be used to assist in the proving the suspension of the socket. Fitting evalu;
In transpelvic amputees, the soft tis- After the positive model has been rec- ing, a
sues on the involved side are con- tified, a clear, diagnostic test socket is tion (
toured as if the iliac crest was still created from a lightweight thermo- Tl1
present. This improves suspension and plastic material. The transparency of resen-
provides a more normal appearance the socket enables visual examination contr
under clothing. Achievement of com- of the underlying tissue and its re- prosil:
fortable anterior/posterior compres- sponse when weight-bearing pressure proce
sion dui-ing the casting process yields a is applied 16 (Figure 10). The test tient
socket that will offer the wearer good socket is modified until both the pa- are n
control over the prosthesis. tient and the prosthetist are satisfied nal n
Measurements can then be taken with socket comfort and security. Pro-
and bony landmarks noted on the ceeding methodically at this phase of
LinE
stockinette. The casting apparatus is the fitting process helps to achieve the Low-
then removed and up to 6 layers of optimal result. for
Figure 7 The anatomically correct hip
35-cm elastic plaster is wrapped trans
disarticulation socket captures the isch-
ium, allowing better stabilization of the snugly around the residual limb, be- Suspension surfa
prosthesis in medial-lateral and antero- ginning on the anterior, moving to The hip disarticulation socket is sus- sized
posterior directions. pended by locking onto the 'waist just ally t
the inferior, then up laterally around

. Chapter 45: Hip Disarticulation and Transpelvic Amputation: Prosthetic Management 569
Figure 10 This view looking downward

Figure 8 Lateral force applied to the glu- Figure 9 This casting apparatus employs into a clear test socket shows how the
teals is an important part of casting and anterior and posterior impression plates skeletal structure of t he pelvis is encased.
unat- fitting the socket. for compression, with a soft tube used Th e casting apparatus is positioned on
iin this for contouring above the iliac crests. t he outside of the socket, demonstrating
ng the t he anterior/posterior compression.
I distri· above the iliac crest on both sides.
The upper border is usually trimmed the sound leg and then stretching the
just proximal to the iliac crests. The liner up around the user's trunk (Fig-
border can be an inch or so higher in ure 13) . 1:his added layer between the
rest. It
some cases, if no rib impingement skin and the socket absorbs some of
)Id ex-
occurs during s1ttmg. For the the frictio n that occurs during ambu-
ly and
transpelvic socket, the dfatal trimlines lation. 17 ' 18 The liner should reduce
ly, the
are often so low that the anteroinfe- abrasions to the skin, and the elastic-
1in and
rior border of the socket contacts the ity of the material increases patient
ression
patient's thigh musculature during comfort and long-term use. Patients
> place,
d caus· sitting (Figure 11). The best proce- with notable areas of tissue break-
plaster dme is to start with extensive proxi- down are especially good candidates
Lcement mal and distal trimlines and trim in for a low-modul us gel liner.
srnalJ increments, allowing both the
patient and the prosthet.ist time to re-
evaluate the fit during sitting, stand-
Other Components
een rec· ing, and walking after each modifica- The foundation of a functional, prop-
;ocket is tion (Figure 12). erly aligned hip disarticulation/
thermo- The final trimlines inevitably rep- transpelvic prosthesis is a well-fitting,
rency of resent a compromise between socket comfortable socket Selection of the
nination control and patient comfort. The remaining components and determi-
:l its re- prosthetist must explain the fitting nation of the functional length of the
process to the patient, helping the pa- prosthesis are equally important, Figure 11 To capture the gluteal ring on
pressure the sound side, the anteroinferior edge
fhe test tient understand the trade-offs that however (Figure 14). All elements of
of the socket extends quite low and may
1 the pa· are required to achieve an effective fi- the prosthesis must work in harmony contact the proximal thigh during sitting.
satisfied nal result. to achieve comfort and mobility at This improves the user's contro l over the
rity. Pro· this level. limb.
phase of Liners
:hieve the Low-modulus gel liners may be used Hip Joint axis during standing. Patients who re-
for both hip disarticulation and The mechanical hip joint is attached quire extra stability may prefer a lock-
transpelvic amputees to protect the directly to the socket or rigid frame, ing hip joint with a stride limiter that
surface of the soft tissues. A large- in a location sufficiently anterior to allows only a short stride. Hip flexion
~et is sus- sized prefabricated gel liner can usu- tl1e acetabulum that the weight- bias systems, incorporating a spring-
waist just alJy be modified by cutting a hole for bearing line falls posterior to tl1e hip loaded hip tlrnt uses kinetic energy to

Af
follo,
at 2
6 me
year,
the p
tial
shou
ule a:
rienc
cono
Figure 12 The socket must be comfort-

able w hen the patient sits as well as dur- Lif,
ing standing and walking. The flat sitting
surface on the anatomically correct hip Co
disarticulation/transpelvic socket not only
allows for good support while sitting but
Num
also prevents the soft tissue from slipping atior
out of the socket. disar
tees,
flex the prosthetk thigh forward at recer
toe-off,8 • 19 result in more normal high
knee flel\.rion timing, increasing mid- Figure 13 A low-modulus gel liner gives cone
the user an immediate feeling of support the I
swing toe clearance (Figme 15). and serves as a protective, shock-
absorbing layer between the residual preg:
Knee Joint limb and socket. weig
balait
Knee joints are selected accord ing to
useful for the hip disarticulation and
each user's activity level, just as with Toi l
transpelvic levels. Th e positional rota-
more distal amputation levels. The
tor allows the knee and shin to be ro- Whe
two basic categories of knees are
tated in relationship to the hip, l 6 pros·
single-axis and polycentric.20 Single-
which is important when the user need
axis knees work well for users with
wants to change shoes, sit cross- the 1
lower activity levels, while more active Figure 14 Complete hip disarticulat ion/
legged , or get into or out of a caJ or bod)
individuals often prefer polycentric transpelvic prosthesis-anatomically cor-
similar confined space (Figure 16). rect socket, anterior hip joint, t orque- trim
designs, 21 ' 22 particularly those offer-
The torque absorber allows the foot and shock-absorbing pylon, positional the I
ing increased stance-phase stability.
to rotate in relationship to the pelvis. rotator, polycentric knee, and dynamic-
ing
Many polycentric knees also improve response foot.
The high-level amputee has lost all trad,
swing-phase clearance of the foot. 16•20
physiologic lower limb joints and port
Motion studies conducted at North-
hence has no way to compensate for some hip d isarticu.lation users report
western University confirmed that 24 both
the normal rotation of ambulation. the ability to walk faster with such
fluid-controlled knees (hydraulic or way~
Use of a vertical shock absorber is be-
pneumatic) result in a more normal components.25 When selecting any thetti
lieved to reduce ground-reaction
gait for the hip disarticulation/ prosthetic component, the primary the
forces on the torso in these amputees,
transpelvic amputee.9 Gait analysis goals are minimizing component hip I
increasing amputee comfort and ac-
has demonstrated that fo r hip disar- weight while facilitating a more nor- pute
ceptance of the prosthesis (Figure 17) . 16
ticulation users, hydraulic knees re- mal and energy-efficient gait. a ho
sult in a more normal range of mo- Foot Selection low
tion at the hip joint during <lorn
The type of foot selected for the hip Follow-up Care plas1
ambulation and also contribute to a disarticulation/transpelvic prosthesis
more rapid cadence.23 depends primarily on the user's activ- Physical therapy is absol utely essential posi
ity level. In general, the more respon- to the attainment of an optimal level the:
Rotators and Shock sive the foot mechanism, the more of prosthetic function. The physical spre
Absorbers important the resistance of the knee therapist ideally should have experi- ston
Positional rotators, torque absorbers, unit becomes.9 Dynamic-response ence in gait training with hip disartic- plac
and vertical shock absorbers are often feet provide a sense of active push-off; ulation and transpelvic amputees. Ure

Chapter 45: Hip DisarticuJation and Transpelvic Amputation: Prosthetic Management 571
After fitting the final prosthesis,

fo llow-up visits should be scheduled
at 2 weeks, 1 month, 3 months,
6 months, and 1 year. After the first
year, an annual visit for inspection of
the prosthesis and skin for any poten-
tial problems is prudent. Patients
should also be encouraged to sched-
ule an office visit whenever they expe-
rience pain or have any significant
concerns related to their prosthesis.
Lifestyle
Considerations
Figure 16 A positional rotator allows the
Numerous specia l lifestyle consider- knee and shin to be rotated in relation·
ations should be discussed with hip ship to the hip, making it easier for the
user to change shoes, sit cross-legged, or
disarticulation and transpelvic ampu- get into and out of a car.
tees, particularly if the limb loss is
recent. Some of these topics are Figure 15 The hip flex ion bias system has
highly personal and include such a spring-loaded hip that thrusts the pros-
thetic t high forward at toe-off. This
concerns as toileting, sex, selecting
"shortening" of the leg allows for better
the right undergarments, considering ground clearance of the foot.
pregnancy and childbirth, controlling
weight, and using assistive devices for
balance. Undergarment Selection
Finding appropriate undergarments
Toileting
for use w1der a hip disarticulation or
When urinating, m en can leave the transpelvic socket can be another
prosthesis in place, but women often challenge. Commercial stockinettes
need to remove it, particularly when and knitted body stockings are avail-
the trimline is at the midline of the able, but many patients prefer to
ilation/
lly cor- body. The prosthetist should consider modify sports clothing for this pur-
torque- trimming the socket, if possible, so pose. Unitards, bicycle shorts with
sitional the user can urinate without remov- one leg sewn shut, and homemade
{namic-
ing the prosthesis. This entails a cotton or Spandex garments are a few
trade-off-less weight-bearing sup- of the more common options.26 Many
port but greater convenience. For women find it helpful to wear a long-
report both men and women, it is almost al- line bra that extends into the proxi-
h such ways necessary to remove the pros- mal trimlines of the socket to prevent
11g any thetic limb for a bowel movement. In the tissue from forming rolls that are
,rimary the not unusual situation where the easily pinched by the socket edge.
1ponent hip disarticulation or transpelvic am-
>re nor· putee has a colostomy collection bag, Pregnancy and Childbirth
6
a hole must be cut in the socket to al- Female patients often have concerns Figure 17 Important components often
low access to the stoma. A small related to pregnancy and childbirth. 26 used in hip disarticulation/transpelvic
prostheses include a torque/shock-
donut-shaped ring of soft, flexible Many hip disarticulation and trans- absorbing pylon, positional rotator, and a
plastic that encircles the stoma and pelvic amputees can become preg- polycentric knee.
essential positions the bag on the outside of nant, carry to term, · and have a
nal level the socket may be used. The ring also normal vaginal delivery. Although
physical spreads socket forces away from the pregnant women can continue wear- comfort, energy expenditure, and
: expen- stoma region so that no pressure is ing a prosthesis, most eventually find other personal considerations. A sup-
disartic· placed arou nd the collection bag (Fig- crutches to be more practical by the portive maternity sling that extends
1tees. ure 18) . second or third trimester, based on under the abdomen can be very help-

essential to their stability and balance ti

while using the prosthesis. 26 B
L
a
Summary R
Clear communication and llllder- c
5
standing between the prosthetist and y
the hip disarticulation or transpelvic
IO. P
amputee is critical to functional suc-
it
cess. Both must be willing to over- e:
come the inevitable frustration asso-
11. S
ciated with creating a prosthesis for
ti
loss at these high levels. The efforts of D
a detail-oriented, methodical, com- a
municative prosthetist in combina- (
tion with optimally aligned compo- 12. S
nents well suited to the patient's Jr
physical abilities and aspirations will ),
result in significantly greater patient l
Figure 18 This soft plastic ring is posi-
tioned between the colostomy bag and acceptance and long-term success 13. P
the skin, distributing socket forces away with these prostheses (Figure 19). ti
from the stoma area. ];
Figure 19 This young hip disarticulation References 14. l

fu1 when the patient is not wearing ti
amputee demonstrates high functional- l. Waters RL, Perry J. Antonelli D, Hislop
the prosthesis. Hip disarticulation ity, participating in rock climbing and H: Energy cost of walking of ampu- F
other highly physical activities. 1
amputees have the advantage of an tees: The influence of level of amputa-
intact pelvis, which supports the tion. I Bone Joint Surg Am 1976;58: 15.1'
a
weight of the uterus during preg- hip disarticulation and transpelvic 42-46.
nancy. As the size of the abdomen in- amputees may prefer to remove the 2. Steen Jensen J, Mandrup-Poulsen T:
creases, the socket can be trimmed prosthesis after work. Sitting on the Success rate of prosthetic fitting after
and modified as needed. Significant major amputations of the lower limb.
floor to play with young children, for
alterations of the socket are required Prosthet Orthot Int J983;7:119-121.
example, is often easier without the
to accommodate the body cha11ges 3. Shurr DG, Cook TM, Buckwalter JA,
prosthesis. Transpelvic amputees may
during pregnancy, so that fabrication Cooper RR: Hip disarticulation: A
benefit from use of a sitting socket prosthetic follow- up. Orthot Prosthet
of a new socket is usually required af- when they are not wearing the full 1983;37:50-57.
ter delivery. prosthesis, 27 particularly if they use a 4. McLauri11 CA: Hip Disarticulation
Weight Control wheelchair part or all of the time. Sit- Prosthesis, Report No. 15. Toronto, Can-
ting sockets are also recommended as ada, Prosthetic Services Center, De-
Obesity can severely limit any ampu-
a protective measure when hip disar- partment of Veterans Affairs, 1954.
tee's ability to walk with a prosthesis,
ticulation or transpelvic amputees 5. McLaurin CA, Hampton F (eds): Di-
but it is particularly troublesome for
participate in sporting activities with- agonal Type Socket for Hip Disarticula-
hip disarticulation and transpelvic tion Amputees. Chicago, IL, Northwest-
amputees. Excess weight adds stress to out a prosthesis.
ern University Prosthetic Research
the sound leg, and adipose tissue on The hip disarticulation or trans-
Center, 1962.
the trunk complicates creation of a pelvic amputee must understand that
6. Lynquist E: Canadian-type plastic
comfortable socket. Swimming is an hopping on the sound leg puts tre-
socket for a hemi-pelvectomy. Artif
excellent ru1d safe way for hip disar- mendous stress on the joints and foot. Li,:nbs l 958;5:130-132.
ticulation and transpelvic amputees Proper use of crutches is far prefera- 7. Radcliffe CW: The biomechanics of
to exercise for weight control because ble to hopping for long distances. 26 the Canadian-type nip-disarticulation
less stress is put on the joints. Crutches that are not fitted correctly, prosthesis. Artif Limbs 1957;4:29-38.
however, can cause shoulder strain 8. Michael J: Component selection crite-
Considerations When the and problems with the joints and ria: Lower limb disarticulations. Clin
Prosthesis Is Not Being Worn nerves in the arms and hands. A large Prosthet Orthot 1988; 12:99-108.
Just as many people like to take off percentage of hip disarticulation and 9. van der Waarde T, Michael J: Hip dis-
their shoes when they come home, transpelvic amputees find a cane to be articulation and transpelvic amputa-

Chapter 45: Hip Disarticulation and Transpelvic Amputation: Prosthetic Management 573
ice t ion: Prosthetic management, in am putee. Ort/10t Prosthet 1985;39: 22. Oberg KET, Kamwendo K: Knee com-
Bowker )H, Michael JW (eds): Atlas of 44-47. ponents for the above-knee ampu ta-
Limb Prosthetics: Surgical, Prosthetic, 16. Jeffries GE, An gelico J. Denison A, tion, in Mw·doch G, Donovan RG
and Rehabilitation Principles, ed 2. Kaier J: Prosthetic Pr imer: Fitting for (eds): Amputation Surgery and Lower-
Rosemont, IL, American Academy of hip disarticulation and hemi- Limb Prosthetics. Oxford, England,
Orthopaedic Su rgeons, 2002, pp 539- pelvectomy level am putations. In Blackwell Scientific Pub]jcatfons,
er-
552. (Originally published by Mosby- 1988, pp 152-164.
ind Motion March/Ap ril 1999;38-45.
Year Book, 1992.) 23. Van Vo rhis RL, Ch ildress DS: Kine-
vie 17. Haberman LJ, Bedotto RA, Colodney
10. Pitkin MR: Effects of design varian ts matic aspects of the Canadian hip dis-
uc- EJ: Silicone-only suspension (SOS) for
in lower-lim b prostheses on gait syn- articulation prosthesis: Preliminary
'er- the above-knee amputee. J Prosthet
ergy. J Prosthet Orthot 1997;9: 113- 122. resuJts, in Murdock G (ed): Amputa-
so- Orthot 1992;4:2:76-85.
u. Sabolich J: Contoured adducted tion Surgery and Lower-Limb Prosthet-
for 18. UellendahJ J: Prosthetic socks and lin- ics. Oxford, England, Blackwell Scien-
trochanteric-controlled alignmen t ers, in First Step: A Guide for Adapting
, of tific Publications, 1988, pp 245-249.
method (CAT-CAM): Introduction
,m- and basic p rinciples. Clin Prosthet
to Limb Loss. Knoxville, TN, Amputee 24. O'Riain M: Report: Clinical Data on
na- Coalition of America, 2001, vol 2, Floor Reaction Forces: Shear. Ottawa,
Orthot 1985;9:15-26. pp 56-58.
po- Canada, Royal Ottawa Rehab ilitation
12. Sabolich J, Guth T: The CAT-CAM-
nt's 19. Haslam T, Wilson M: Hip Flexion Bias, Center, 1985.
HDTl-1: A new design for hip d isartic u-
will Concept 80. Houston, TX, Medical 25. Michael J: Energy storing feet: A clini-
lation patients. Clin Prosthet Orthot
Center Prosthetics, 1980. cal comparison. Clin Prosthet Ortl10t
tent 1988;12: 119- 122.
20. Gard SA, Childress DS, Uellendahl JE: 1987;11: 154- 168.
cess 13. Angelico J: Sockets for hip d isarticula-
The influence of four- bar linkage 26. Skoski C: HP/HD Help. http://
tion and hemipelvectomy amp utees. h phdhelp.org/abo utthe.htm. Accessed
knees on prosthetic swi ng-phase floor
In Motion Sept/Oct 2001;19-20.
clearance. J Prosthet Orthot 1996;8: January 29, 2002.
14. Imler C, Q uigley M: A technique for 34-40. 27. Moretto DF, Minkel JL, Cardi MD:
thermoforming hip disarticulation Prosthetic/o rthotic management afte r
slop 2 I. Michael JW: Prosthetic knee mecha-
prosthetic sockets. JProsthet Orthot recent hemipelvectomy for a myelo-
I· nisms. Phys Med Rehabil 1994;8:
1990;3:34-37. meningocele patient. JProsthet Orthot
uta- 147-164.
15. Madden M: The flexible socket system 1992;4:93- l 02.
as applied to the hi p disarticulation
r:
'ter
nb.
IA,
1et
Can-
e-
l.
Di-
1,1la-
west-
if
of
!tion
38.
:rite-
~;lin
dis-
uta-

ln1
Abh
mar
amf
am1
exte
hen
tem
For·
con
hab
fitti
lior
pro
tior
tun
mol
sph
the
dia1
alit
bot
and
ten:
evil
sup
pat
tier
con
the
Op~
dee
car,
The
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mo
Translumbar Amputation:
Surgical Management
Jose J. Terz, MD
Introduction
Ablation of the caudal half of the hu- nonlocal disease. Finally, the increas- malformations). 1 Only rarely will pa-
man body described by the level of ing success of chemotherapy and ra- tients with significant spinal cord in-
amputation is termed translumbar diation is challenging the TLA, with jury resulting in paraplegia, loss of
amputation (TLA); described by the its modest chance to cure disease and potency, insensate anal sphincter,
extent of amputation, it is termed extraordinarily high morbidity. chronic urinary tract disease due to a
hemicorporectomy. TLA results in ex- neurogenic bladder, and severe pres-
tensive loss of structure and function. sure ulcers be candidates for TLA. 2
Fortunately, advances in surgical re-
Patient Selection Patients with squamous cell carci-
construction, physical and social re- A TLA cannot be planned and accom- noma of paretic dysfunctional limbs
habilitation, prosthetic materials and plished within a short period of time. have also been treated with TLA. 3 •4
fitting, and functional aids can ame- Patients must be gradually advised of These tumors, however, may be quite
liorate the ravages of this surgical the losses they will face and the rela- aggressive, making them inappropri-
procedure. Unlike all other an1puta- tive benefit of the operation in arrest- ate for treatment by a surgical proce-
tions, TLA involves the loss of struc- ing the disease process and alleviating dure witb a recovery period that ap-
tures used in functions other than the symptoms. Patients must be given proaches 6 months to 1 year (Table
mobility and manipulation. T he latitude in deciding on the operation, 1). Also, despite the functional losses
sphincteric and storage functions of and it may be anticipated that a pa- and significant structural distortion
the anus and rectum and urogenital tient will cancel or delay the planned associated with this condition, few
diaphragm and bladder are lost. Sexu- TLA. The surgeon and rehabilitation patients would consider loss of these
ality is severely diminished because team must be sensitive to this reluc- cumbersome limbs and dysfunctional
both internal and external endocrine tance and respond with additional structures valuable or necessary.
and reproductive organs are lost. Ex- support and education. Coercion, in- "Looking whole," even when the
tensive postoperative problems are in- timidation, or incomplete discussion whole is defective, is psychologically
evitable, charging the surgeon and the of the extent of the operation will unimportant. The need for intactness of
support team witb the task of careful dermine the team's ability to provide the body becomes one of the major
patient selection and preoperative pa- optimal patient care and endanger the driving forces in the patient's rehabil-
tient and family education, including requisite strong patient-physician re- itation after TLA. The rehabilitation
communicating with absolute clarity lationship. must be structural and functional.
the risks and benefits involved. This In general, patients who are eligi- An evaluation of the extent of the
operation is being performed with ble for TLA will have a local disease primary disease should include an
decreasing frequency and in a more process that is recurrent or chronic. exhaustive pre- and intraoperative
carefully selected group of patients. Recurrent conditions include low- search for metastases or proximal lo-
The explanation for this is at once grade, nonmetastasizing tumors with cal tumor growth. Diagnosis of the
clear and arcane. Surgical procedures an excellent chance for long-term intrathecal extension of sacral tu-
have, in general, trended toward a re- cure, such as low-grade chondrosar- mors includes MRI, which can differ-
d uction in deformity and functional comas, sacral chordomas, giant cell entiate between tmnor and radiation
consequences. In addition, diagnostic tmnors, or vascular neoplasm (mas- therapy- induced changes.5 MRI can
modalities have improved analysis of sive hemangiomas or arteriovenous also identify any infiltration of the

pend
TABLE 1 Translumbar Amputations divid1
Parameter Patient 1 Patient 2 Patient 3 perfo
60 51 33 stage
Age at surgery (years)
0.25 20
dure
Years from primary 4
diagnosis ease i
Pathologic diagnosis Sacral chordoma Paraplegia, Marjolin's ulcer Chondrosarcoma urina
Number of previous 3 3 4 "clea1
treatments whid
Extenuating circumstances Pain, paresthesias Septic wound Left lower limb paralysis soft-t
Estimated blood loss (mm 3 ) 3,500 8,700 3,000 tion.
Fluid replacement (mm 3 ) dure
Blood 3,250 12,000 2,500 tramJ
Fresh-frozen plasma 1,000 3,800
blooc
Complications Renal dysfunction, acute respiratory Wound separation, candida Wound infection, retained
distress syndrome, hypertension, esophagitis, sepsis, small-bowel spinous process first ~
flap necrosis, myocardial infarct fistula scopi
Length of surgery (hours) 10.5 11.5 7.5 tance
Hospital time (days) 65 133 52 tram1
Post-TLA survival (years) 6.5 0.5 2.0 ment
Status DOD DOD DOD tion
reco.r
Parameter Patient 4 Patient 5 Patient 6 In
the ii
Age at surgery (years) 26 23 29 poste
Years from primary 5 4 4 extell
diagnosis
edge
Pathologic diagnosis Arteriovenous malformation Giant cell tumor Sacral chordoma
the I,
Number of previous 3 2 2
treatments the r
Pain, tumor, erosion to rectum Pain, bowel dysfunction,
sis; tl
Extenuating circumstances Congestive heart failure, buttock
necrosis bladder dysfunction i.mag
Estimated blood loss (mm 3 ) 5,000 7,000 3,500 side.
Fluid replacement (mm 3) abdo
Blood 5,000 3,750 2,500 bony
Fresh-frozen plasma 1,250 1,500 800 infer
Complications Urinary leak, lobar collapse, renal Bleeding, wound separation, Flap necrosis, urinary leak also .
cell carcinoma treated with left hypertension
nephrectomy 9 years after TLA the s
Length of surgery (hours) 13 10.5 13 speci
Hospital time (days) 90 66 31 open
Post-TLA survival (years) 7.0 2.7 10 exp lie
Status NED NED DOD sess 1
tumc
DOD= dead of disease; NED= no evidence of disease
tasta
node
tram
tissu
paraspinal muscles by tumor and sections: soft tissue, bony and neural, surgeon, and a Slll'gical oncologist. any:
soft-tissue masses encroaching on the and vascular. The latter two, once The intraoperative findings will dic- opsi<
dural sac of the nerve roots. Patients undertaken, commit the surgeon to tate the degree of involvement of irrev
in whom the disease cannot be en- completing the ILA, whereas the each of these specialists. Adequate any
compassed completely are not candi- former can be undertaken as the pre- amounts of blood and blood products mor
dates for TLA. liminary portion of the operation and or a system for intraoperative blood perf c
be used as a diagnostic as well as a loss collection and rei..nfusion should logic
therapeutic maneuver. The integrated be prepared. Hemodynamic monitor- soft-
Surgical Technique Slll'gical team includes an anesthesiol- ing with arterial and central venous no e
The strategy for t he surgical portion ogist, a neurosurgeon, an orthopaedic catheters is needed. The positioning A
of a ILA can be divided into three surgeon, a urologist, a reconstructive of the patient after intubation will de- is cc

Chapter 46: Translumbar Amputation: Surgical Management 577
pend on the surgical plans for the in- fleeted superiorly by dividing the bal- and arterial blood pressure. The aorta
divid ual patient. The surgery may be ance of the anterior abdomu1al m us- is transected sharply and the distal
performed as a single-stage or n.vo- cles, and attention can be directed end is then oversewn. The proximal
stage procedure. The two-stage proce- towai·d division of the intra- portion of the aorta is closed with a
dure consists of initial analysis of dis- abdominal vascular structures and running 3-0 monofilament vascular
ease extent and diversion of fecal and soft tissues. The ureters are identified suture. The vascular clamp is released
urinary streams before the second, at or above the level of the common one or two clicks and any additional
"clean" portion of the operation, iliac vessels. Consideration of tumor hemostasis is secured with inter-
which involves bony, vascular, and location , previous radiation therapy, rupted sutures. In rare instances, su-
ysis soft-tissue resection and reconst:ruc- and planned urologic reconstruction tures and pledgets may be required
tion. The use of a two-stage proce- will determine the level of u reteral di- because of atherosclerotic changes or
dure also distributes the surgical vision. Care is taken to preserve the injury from previous radiation ther-
trauma, including tiss ue injury and entire length of the ureter with its en- apy. Communication between the
blood loss.6 If technically feasible, th e veloping blood supply. Because of the surgeon and the anesthesiologist is
ined
first stage could be performed laparo- level of amputation, most of the critical in anticipating and monitor-
scopically or with laparoscopic assis- blood supply to the ureters wiJl de- ing the sudden loss of venous return.
tance, further reducing the surgical scen d in a caudal direction from the The vena cava, which has been p re-
trauma. The incisions and/or place- renal pelvis. At the time of u reteral di- pared and controlled, is clamped and
ment sites m ust anticipate the resec- vision , a large clip or a tie is placed on divided in a ·simila1· manner. Often, a
tion incision, margins, and flaps for the proximal portion of the ureter to thinner suture material ( 4-0 monofil-
reconstruction. allow dilation before reconstruction. ament) can be used for the closure. At
In both a si ngle- or two-stage TLA, The aorta and vena cava are mobi- the surgeon's discretion, vascular sta-
the initial incision begins at the most lized above their b ifurcations and be- pling devices may be used for these
posterior aspect of the iliac crest and low the renal artery and veins. If nec- steps.
extends anteriorly, along the inferior essary, the inferior mesenteric artery With the completion of mobiliza-
edge of the anterior abdominal wall at can be- d ivided. Mobilization of the tion and division of the aorta and
a the level of the inguinal crease along great vessels will invariably require di- vena cava, attention is turned to the
the pubic bone to the pubic symphy- vision of on e or two of the lumbar right and left sides of the retroperito-
sis; the incision con tinues in a mirror vessels and the right gonadal ar tery. neum. O n the righ t side, the gonadal
ion,
I image pattern on the contralateral After complete mobilization, the vein, and on the left side, t he gonadal
side. The muscles of the anterolateral aorta is cross-clan1ped by placing a artery and vein are the primary
abdominal wall are divided from their vascular clamp approximately 2 cm remairung retroperitoneal vascu.lar
bony insertions onto the pelvis. The cephalad to the planned di vision site. structures to be ligated and divided at
inferior epigastric artery and vein are Communication between t.l1e anes- the level of the planned m uscular
{ leak also divided at this time. In the male, thesiologist and surgeon is required at transection. The base of the small-
the spermatic cords are left with the this point to ensu re precise evaluation bowel mesentery with the r ight and
specimen. The abdomen is then of changes i11 arterial blood pressure, ileocolic vessels, cecum, and right co-
opened. 1n the one-step proced ure, an urine output, and central venous or lon are mobilized cephaJad in a man-
exploration can be performed to as- left ventricular end diastolic pressure ner similar to that used in a right ret-
sess the intra-abdominal extent of the (pu.lmonary capillary wedge pres· roperitoneal lymph node dissection.
tumor and potential sites of me- sure). Because of the marked reduc- The right colon and terminal ileum
tastases, including the per iaortic tion in total vascular space, acute hy- will be used to construct a continent
nodes above the planned level of pertensive changes may require reservoir for the urinary diversion
transection {L3-L4), paraspinal soft stepwise clamping with the addition ( with loss of the ileocecal valve and
tissues, and the liver paren chyma. If of peripheral vasodilators {nitroglyc- most of the right colon), so preserva-
cologist. any suspicious findings are noted, bi- erine) and mild volume reduction tion of maximum colonic length is
Nill die· opsies can be performed before any (diuresis). It is best to have kept the in1portant. Care must be taken in di-
nent of irreversible steps are taken. If ther e is patient euvolemic or slightly hypo- vid ing the sigmoid colon at its most
~dequate any doubt regarding the level of tu- volemic with a brisk urine o utput in distal, viable extent. This is especially
products mor infiltr ation, a biopsy should be preparation for this maneuver. Au to· important if the inferior mesenteric
'o/e blood performed an d evaluated \'\rith histo- transfusion maneuvers- lifting the artery has been ligated at its takeoff
11 should logic procedures to ensme that the lower limbs or placing the patient in from the aorta. The paired structures
monitor· soft-tissue margin is adequate, with a Trendelenburg position-may be of the retroperitoneum, including the
.1 venous no evidence of pathology. used with extreme caution and care· sympathetic trunk, psoas muscle, and
,sitioning After the resectability of the tu mor ful monitoring of central venous genitofemoral and femoral nerves, are
ri will de· is confirmed, the anterior flap is. re- pressure, p ulmonary artery pressure, divided. The musculature of the pos-

The patient can be turned supine After adequate mobilization of the

to begin the anterior and intra- distal portion of the colon and reex-
abdominal portions of the procedure. amination of vascular integrity, an
When the condition requires a pri- end colostomy is formed in a location
mary anterior approach, such as in that will be comfortable for the pa-
patients who require abdominal ex- tient, usually in the center of the left
upper portion of the anterior abdom-
ploration or biopsy of retroperitoneal
or anterior paraspinal musculature, inal wall flap. Care must be exercised
I
the division of the bony and neural in planning a stoma that will not be
elements is the final step in the TLA. compressed by the upper edge of the
When this approach is used, the disk prosthetic bucket.
space is identified at the planned level The flap closure is performed in
Figure 1 Standard flap technique. The layers, approximating the well-
of the TLA. The disk is removed or
anterior and posterior skin f laps are defined fascia of the anterior abdomi-
closed primari ly. The paired stomas on divided sharply with a knife and the
nal wall to the Jurnbodorsal fascia
t he abdominal wall are at approximately dural sac is identified anteriorly. T he
with interrupted, permanent suture
the level of the umbilicus. The position- sac is opened and the neural elements
ing of the stomas takes into account the material. The subcutaneous tissues
ligated and divided. T he final division
planned design of a bucket prosthesis. are closed with interrupted absorb-
of the transverse process and spinous
able suture and the skin with metal
process is performed with an os-
terior abdominal and lumbar areas is teotome. Significant bleeding from
staples or monofilament suture. The A
colostomy and urinary pouch stomas
divided at a level selected to preserve the spinal a rtery and veins may occur
can then be matured and all wounds Figu1
the maximum amount of vascularized at this step. If the bleeding is not eas-
covered with appropriate dressings or line·
soft tissue for closure. ily controlled, packing with sponges t issu,
drainage bags. A net-type dressing
The division of the bony structures can tamponade the vessels and allow the I
covering the TLA stump helps in se-
(vertebral bodies, transverse pro- for better exposure of these vessels by rel at
curing the dressings to the wound gical
cesses, and spinous process) and the completing the soft-tissue division.
without placing tape on the skin of tran:
dural sac with the spinal cord can be The posterior skin and remaining the tenuous flaps (Figure 1). the E
musculature are rapidly divided. The If large amounts of skin are to be
approached in one of two ways. In pa-
specimen is removed from the surgi- removed, flap reconstruction with rior
tients with neoplastic disease that ex-
cal field and meticulous hemostasis is myocutaneous or fascia! cutaneous cam
tends proximally along the dura or
secured along the dura, in the flaps can be considered. OccasionaJly, epig
meninges or in patients in whom pre-
paravertebral muscles, and along the tissue can be preserved from one or tion
operative evaluation suggests possible
skin edge. Care should be taken to re- both of the lower lirnbs. 10 One such perf
tumor extension intrathecally above a
sect any posterior elements (spinous flap uses the skin, subcutaneous tis- the
resectable level, the surgical proce-
or transverse processes) or residual sue, and muscle perfused by the fem· intr;
dure shot1ld begin with a posterior el-
vertebral bod ies that may cause com- oral artery1 1 (Figure 2) . The use of fals~
ement laminectomy from approxi- pression on the posterior flap. free flaps has not been attempted but 25%
mately Tll to L3. This may have been Continent urinary diversion has ter.ic
may provide an additional alternative
done as the first stage of a two-stage been used more recently with creation as a
for coverage of the soft-tissue defect
approach. This initial exploration can of an Indiana pouch, 8 •9 which is the rior
and closure of the wound. This form
be extended to include opening of the formation of a detubularized reser- trea
of reconstruction would be best
dura, division of the cauda equina (at voir from the right colon combined apy
planned in a two- or even three-stage
the Ll-2 level), and repair of the with plication of the terminal ileum procedure, assuming that only soft· boli
cephalad dura division. Caution and submucosally tunneled ureters. tissue/cutaneous coverage would be mat
should be exercised in dividing the The result is a 350- to 700-mL conti- lacking. A temporary biologic dress· con
cauda equina in patients with neu ro- nent reservoir that requires catheter ing may be required while the patient SUpj
logically intact lower limb ftmction, drainage approximately every 5 to recovers from the ablative stage of the cioc
and functional bladder and anal 6 hours. The stoma is created by using procedure. I
sphincters. Spinal shock requiring the plicated terminal ileum and is tien
volume expansion m ust be treated placed through the anterior body wall and
with consideration of the reduced flap in the mid to upper right quad-
Comp I ications ne..,
vascular volwne and risk of acute rant. After initial healing, no ostomy The complications of TLA are prirna· sup
pulmonary edema.7 Meticulous he- bag is required, and the difficulty in rily related to flap for mation, urinary dyn
mostasis is essential to prevent an epi- fitting the patient in a bucket prosthe- reconstruction, and the extensive sur- incr
sis is reduced. gical procedure (Table 1). The a11te· prei
dural hematoma.

Chapter 46: Translumbar Amputation: Surgical Management 579
the
:ex-
an
:ion
pa-
left /
::>m-
ised
t be
I
: the I
I
I
I
din I
l I
I
well- I
I
I 'l
I
::>mi- l \('
II
,,,,,,
I
·ascia I Ii
I
1ture
,,
I
I
I
ssues I I I
,orb- 'I I
I
I
I
netal 'I I
I
I I
I
. The A B c D
omas
>Unds Figure 2 Condition requiring flap reconstruction. A, Anterior view. The tumor arises in the right true pelvis and extends across the mid·
1gs or line to include the sacrum and lowest lumbar vertebrae. The tumor has penetrated the posterior pelvic wall and extends into the soft
essing tissues of the buttock. The dotted line delineates the incision beginning at the right iliac crest and extending along the pubis and on
the left thigh to create the myocutaneous flap. The aorta and left iliofemoral vessels are schematically outlined. B, Posterior view. The
in se-
relationship of the tumor to the bone and soft tissues is shown. C, Anterior view. The area outlined by dotted lines represents the sur-
1ound gical specimen. The anterior thigh flap with its supporting vessel is shown. D, The completed resection w ith the anterior thigh f lap
(in of transposed to cover the inferior defect is shown. The Indiana pouch urinary diversion stoma is seen in the right upper quadrant and
the end colostomy in the left upper quadrant.
to be
with rior flap will have distal ischemia be- aspects of the flap. It is important to Problems with the urinary diver-
meous cause of the division of the inferior remove all posterior bony elements to sion system occur in both the imme-
anally, epigastric artery and vei n. In addi- minimize pressure points on the flap. diate and long-term postoperative pe-
::>ne or tion, the closure of the flaps may be A variety of specialized beds have been riod. The initial problems are related
e such performed under tension because of designed to reduce pressure areas and to urinary leaks from the conduit and
,us tis- the reduction in the volume of the shear effect. The beds are constructed the site of ureteral implantation.
1e fero- intra-abdominal space (loss of the as either a series of air cells that inflate These are treated with diversion and
use of false and true pelvis, or approximately in a cephalad-caudal and right-to-left drainage, and usually do not require
ted but 25% to 30% of the volume). The pos- sequence or as fluidized ceramic mi- formal revision. In the chronic phase,
:rnative terior flap will be relatively ischemic crospheres within a monofilament problems are related to urinary tract
: defect as a result of the division of the poste- polyester filter sheet. These beds serve infections; chronic reflux (prevented
is form rior musculature and because of prior primarily to automatically shift the by the nonrefluxing ureteral implan-
,e best treatments, especially radiation ther- patient's position and prevent pres- tation in the [ndiana pouch); 9 and
ee-stage apy for sacral malignancies and em- sure, shear, and friction. metabolic problems related to pouch
ly soft- bolization for arteriovenous malfor- Hypertension is an unusual post-
bicarbonate wasting that results in
)Uld be mations. These factors may also operative problem that occurs during
hyperchloremic metabolic acidosis.
c dress- contribute to the tenuous vascular the first postoperative week. This con-
These metabolic problems are more
: patient supply to this myocutaneous or fas- dition often requires a combination of
common in patients with colonic-
;e of the ciocutaneous flap. diuretics, central a.-adrenergic stimu-
based conduits.
In the postoperative period, the pa- lators, peripheral a.- and P-blockers,
tient can be placed in only the supine and angiotensin I-converting enzyme
and lateral positions because of the inhibitors. Although hypertension was Postoperative
new stoma, the need for respiratory thought to occur as a result of volume
Management
e prima- support on the ven tilator, and hemo- expansion during surgery, it may per-
, urinary dynamic monitoring. This positioning sist indefinitely even after a return to The early postoperative period is
1sive sur- increases the shear and compressive the correct preoperative volume status marked by redistribution of the large
'he ante- pressure on the posterior and lateral adjusted for the new body size. volumes of blood and other fluids re-

Figure 3 A patient who underwent TLA for arteriovenous malformation (patient 4 in Table 1) shown prone (A) and supine (B). Note
t hat the flap has a major anterior component and the final suture line is on the posterior aspect. Th e upper aspect of the mons pubis
is seen j ust to t he right of the midline posteriorly. Th e stomas were placed in the lower portion of the flap (right-sided ileal conduit;
left-sided end colostomy). C, The patient is independently supported in the bucket prosthesis w it h good access to the stomas and their
appliances. D, The patient is prepared for mobility in a wheelchair.
placed intraoperatively. The blood transfer and locomotion. These exer- through to the postoperative period.
loss may range from 3,000 to 8,500 cises all begin in the bed with range- Although the rare patient may begin
mL, and replacement with packed red of-motion activities, lifting of light to have an adequate protein and calo-
cells, whole blood, and fresh frozen weights, and use of the trapeze. Pa- rie intake at 7 days postoperatively,
plasma is required. Care is taken to tients gradually progress to self- most patients do not achieve this nu-
prevent p ulmonary overload and re- mobiliza tion in the wheelchair and tritional goal until about 3 to 4 weeks
nal dysfunction by using volume use of a self-propelled gw-ney stretch- postoperatively. Patients who have al-
assessment with central venous or er. Because of positioning require- ready had a urinary diversion or co-
pulmonary artery catheters. As men- ments and pain, patients find it diffi- lostomy formation performed in stage
tioned, hypertension can be a prob- cult to maneuver a wheelchair early in one are more likely to achieve nutri-
lem and appropriate interventions are the postoperative period and instead tional goals early. The use of centrally
required. Following ex:tubation, pause a gurney, which can be operated administered glucose and amino acid
tients begin a slow readjustment to from a prone position. This is nor- mixtures with supplemental lipids
the upright position. They must over- mally the first method of self- can bridge the nutritional hiatus dur-
come significant deficits in balance mobilization and travel outside of the ing the return of bowel function,
and transfer. The bed is initially room. Patients are generaJly able to healing of intestinal anastomoses that Figur
result from harvesting the urinary di- chair
equipped with a trapeze device to carry out this activity 1 to 2 months
seen
encourage the patients to pull the postoperatively. With additional edu- version conduit, and resolution of the limbs
upper torso up enough to look cation in transferring, gain of self- noninfectious diarrhea related to the onU
around and to strengthen the upper confidence, and fitting in the bucket reduction in bowel length that is fre·
part of the body. Preoperative upper prosthesis, patients can begin to use quently required in these patients.
limb strengthening may facilitate this a standard or motorized wheelchair Pain is a significant component of alge~
phase of recovery and rehabilitation.3 as their primary means of mobility the disease process in almost all pa- (oxy
The sense of being able to move from (Figure 3). tients who undergo TLA. In some pa- hydr
side to side and arise from the su- Maintenance of nutritional status tients, preoperative pain wilJ have anal,
pine position has psychological bene- in the preoperative and early postop- been a major motivating factor in dein
fits. Sitting upright is accom- erative periods can be difficult. Pa- deciding to undergo the sw-gery. men
plished by graduating through a series tients with severe pain or chronic in- Postoperative pain can be divided into pain
of sequentially increasing, semi- fectio ns may be malnourished when two categories: incisional and phan- patii
recumbent positions. Care must be first evaluated because of decreased tom. Incisional pain is related to flap colo
taken not to put excessive pressure or food intake and increased metabolic closure and ostomy formation . These- char
shear on the suture line. Upper limb demands. Intravenous aLimentation quential use of intravenous narcotics mas:
strength-training exercises are re- (either total or supplemental) may be (morphine or otl1er narcotics admin- (tra1
quired to develop adequate power for started preoperatively and continued istered through patient-controlled an- ulati

Chapter 46: Tran slumbar Amputation: Surgical Management 581
Note
pubis
nduit;
I their
eriod.
begin
calo-
tively,
is nu-
weeks
1ve al-
or co-
l stage
nutri-
otrally
.o acid
lipids
IS dur-
1ction,
es that Figure 4 Pat ient w ho underwent TLA (patient number 1 in Table 1). A, Patient seated in bucket prosthesis in a wheelchair. The w heel-
ary cli- chair in t he photograph was used early in the rehabi litation process. It was later replaced w ith an automatic, self -propelled model as
seen in C and D. B, Patient wearing cosmetic lower limb prostheses. C, Patient wearing complete (f unctional and cosmetic) prosthetic
I of the
limbs. He is in a powered wheelchair outside the main hospital entrance and is heading t o his specially equipped van. D, The patient
to the on t he hydraulic lift of his specially equipped van. E, The patient preparing to drive home in the van.
: is &e-
nts.
nent of algesia devices), potent oral analgesics Follow-up Evaluation of the appliances or catheterization of
all pa- (oxycodone with acetaminophen, or the pouch. The basic techniques for
,me pa- hydromorphone), and then mild oral The primary surgical procedure and bed-wheelchair transfers are mas-
ll have analgesics (acetaminophen with co- the initial recovery require about a tered. The initial bucket and a cos-
ctor in deine) will be adequate for manage- 2-month hospitalization. During this metic prosthesis for the lower limbs
,urgery. ment of perioperative pain . Phautom period, the patient has the ablative are fashioned. Muscular attrition, res-
led into pain is far more complex, and many surgery aud care for any initial post- olution of edema along suture lines
l phan· patients require a variety of pharma- operative problems. Education re- and in flaps, and general redistribu-
I to flap cologic (oral and epidural agents), me- garding the care of the colostomy is tion of stomal location will likely re-
.These· chanical (changes in position and provided and may include the use of quire sequential modifications of the
1arcotics massage), and electrical stimulator y stomal supplies, techniques of irriga- prosthesis. 12 The return to main-
ad min· (transcuta.neous electrical nerve stim- tion, and other aspects of care of the stream society requires that the pa-
,lied an· ulation) modalities for control. urinary diversion system, such as use tient be able to move not only within

Translumbar Amputation:
1y.
eps
Greg Gruman, CP
ID
rg-
110,
et al:
Introduction
Translumbar amputation (TLA; also bulation is easier after TLA because son born without legs and pelvis will
from the weight of modern prosthetic make good use of a prosthetic socket
called hemicorporectomy) represents
;h for upright balance and several differ-
a heroic effort to save the patient's life limbs is but a fraction of the weight of
t ent forms of mobility aids. Appropri-
in the face of severe trauma, infec- the portions of the body that were
tion, or cancer. 1-9 These patients amputated.1,2.9,11,13,1s,11,1s ate management may include a socket
pee ts mounted on a caster cart for floor-
therefore require a special degree of A successful fitting can be with a
993;
care from the entire medical and sitting prosthesis with limbs for cos- level mobility and a standing-height
prosthetic team. Success depends on mesis only, or with a legged prosthesis frame. Floor-level mobility will phase
,orec-
the full cooperation of both the med- used for upright ambulation. As de- into wheelchair use. The prosthetic
24. 4
ical professionals and the amputee. scribed by Smith and associates, a socket should be lightweight and have
ton L, a suspending shoulder strap so that it
,orec- Prior to surgery, the surgeon will proper prosthesis will meet the follow-
ensure that the patient understands ing criteria: ( 1) stable upright posture automatically moves with the user
nt: A
both the outcome of the procedure and maximum upper lin1b freedom, from place to place and from one piece
litera-
and the potential for rehabiilita- (2) maintenance of soft-tissue sup- of mobility equipment to the other.
tion.4·10·1 1 Ideally, the patient will port, (3) minimal weight bearing on The bottom of the socket/platform
.,Robb
have a good support system including the vertebral column, and ( 4) irnim- will come into contact with the floor
:ny
)$. fam ily and friends and will have com- peded respiratory and stomal drain- and with caster cart and wheelchair
pleted a realistic goal-setting process.8 age. The literature reports numerous platforms. It should have a "footprint;'
The purpose of preprosthetic therapy cases of successful prosthetic fitting or tread area, just large enough to pro-
l, Cross is strengthening of the entire upper following TLA, includi ng a few in- vide hands-free stability.
,gement part of the body because the upper stances where patients achieved in-
New limbs will be relied on for mobility dependent household and limited
abil following amputation. 8 • 10-12 community ambulation.2•5•6·8 - 17•19-22
Because the TLA has been per- However, some reports of legged
formed only since 1960 and is rarely household/community ambulation
encoirntered in clinical practice, pros- may be based on hopeful extrapola-
thetists, therapists, and physicians tions from initial clinical demonstra-
tend to feel overwhelmed when faced tions rather than long-term follow-up.
with this challenge6 •8 •11 - 16 (Figure 1). Regardless of the patient's interest in
Prior experience with individuals ambulating with prostheses, it is al-
with paraplegia is very good prepara- ways useful to direct prosthetic man- Figure 1 Typical appearance of t he pa-
tio n for working with the TLA survi- agement toward optimizing the trans- ti ent following translumbar amputation.
vor. For individuals fitted with a sit- lumbar amputee's function while Note the distal incision and dua l stomas,
using a wheelchair for long-range mo- both of w hich must be accommodated by
ting prosthesis, the loss of the
t he prost hetic socket. (Reproduced with
nonfunctional body parts relieves the bility. permission from Pearlman SW, McShane
arms of the full body weight. The pa- The prosthetic management of RH, Jockimsen PR, et al: Hemicorpectomy
tient who is able to stand with a these patients involves several key defor intractable decubitus ulcers. Arch
legged prosthesis may find that am- cisions regarding expectations. A per- Surg 1976;171:1141.}

584 The Lower Limb
to be the best device for patient com-

fort and mobility. 4 ' 22
The initial design of the sitting de-
vice consists of a level distal surface to
enhance safety and stability (Figure
2). Once comfo1t and a tolerance for
sitting upright have been achieved, a
rocker bottom can be added to allow
for smoother forward progression by
using the arms fo r a swing-tluougb
gait. The specific contour of the
Figure 2 Typical sitting prosthesis with rocker depends on such factors as
rectangular openings for bowel/bladder body weight, torso height, and arm
drainage bags and an extended platform length and is best determined by dy-
Ri
for stability. A semicircular cutout in the namic alignment of the prosthesis st
platform allows the amputee to empty during hand walking. Dankmeyer and SC
t he drainage bags into the toilet without
assistance. Base contours must be individ- Doshi 14 have suggested that the f,
proper height for the base is one that in
ualized to provide stability and yet per- (Ii
mit hand walking. (Reproduced with Figure 3 The limited body mass that re- allows placement of the palms flat on ac
a,
permission from Simons BC, Lehman mains following translumbar amputation the floor with slight elbow flexion. di
JF, Taylor N, et al: Orthot Prosthet facilitates independent transfer into a sit- Ideally, it will provide sufficient sta- Ill'
1968;22:66.) t ing prosthesis. (Reproduced with permis-
bility to allow the amputee to pick up
sion from Delateur BJ, Lehmann JF, Win-
terscheid LC, et al: Rehabilitation of the small objects without tipping over
The primary prosthetic chaHenges patient after hemicorporectomy. Arch and yet allow an easy weight shift to
Figu1
with translumbar or transpelvic am- Phys Med Rehabil 1969;50:15.) initiate ambulation.
putations are adequate heat dissipa- Prior to casting for the prosthesis,
tion,23 because these amputees will it is desirable to use a tilt table with neu-
have almost 40% less skin area, and Sitting Prostheses varying degrees of elevation so that and
pressure management for prevention The traditional approach to pros- tl1e amputee can develop a tolerance pro:
of ulcers caused by the unnatural thetic management for transpelvic for the weight bearing required for use<
weight-bearing areas of the prosthe- and translumbar amputations consid- the casting procedure. To allow the gair
sis. Amputees with a paraplegic-level ers a sitting prosthesis as preparatory design of an accurate weight-bearing ti all
lesion are often very active, and the cast, it is generaJJy recommended that fore
to ambulation with a "legged" pros-
the amputee be suspended vertically
function of their arms and hands thesis. Carlson and Wood, 22 however, des'
tends to cause significant shearing from a casting frame . 14' 15' 17 It is im-
have recently suggested that ambula- ost<
motions between the thorax and the portant to place the tissues carefully
tory mobility is not as realistic a goal to 1
proximal brim of the socket, requir- in the position they will occupy in the
as wheeled mobility for this group. con
ing careful design of the socket in this final prosthesis. A11 epoxy resin-
Most authors advise provision of a op~
region. All of these factors are impor- based bandage can be used for the
sitting support system before consid- to
cast and reused later as a temporary
tant in developing a prescription and eration of ambulatory prostheses, and the
prosthesis with the tilt table to in-
treatment plan and require close con- many variants have been detailed in ing
crease the amputee's tolerance for
sultation with the prosthetist. One the literature.1,2,s,6,8-14.1s-20,22 A sit- mu
weight bearing.
key factor is the amputee's interest in ting support system is used after pri- do1
and physical potential for ambula- mary heali11g is complete and while cas
tion. Depression a11d significant med- tile rehabilitation options are being Socket Design str:
ical complications are commonly en- analyzed. The static sitting prosthesis rec
In designing the socket for the trans-
countered, 1·8·10·12 and both can is a good diagnostic tool for assessing ge1
lumbar amputee, the prosthetist must
preclude good function until re- amputee tolerance and cooperation. tis:
precisely identify weight-beaTing and
solved. Physical barriers to prosthetic Greater acceptance will be achieved if relief areas by using multiple trans- ba:
fitting can include gross obesity, 12 in- the amputee is allowed to fully accli- parent test socket procedures. The co.
ability to tolerate an upright posture, mate to the sitti11g device before the major weight-bearing area is the tho- an
and poor upper limb strength. If up- introduction of an ambulatory sys- rax, assisted by containment of the w~
right weigh t bearing is not possible, a tem. The sitting device can also be abdominal tissues. Several areas need
prone cart is usually the most practi- used as a permanent or final prosthe- pressure relief, including the inferior ri,
cal alternative. sis. Indeed, some authors consider it borders of the scapulae, any prorni- th

Chapter 47: Translumbar Amputation: Prosthetic Management 585
om-
; de-
:e to
gure
~ for
~d, a
Bilater I
1llow suspe ion
n by straps rom
top of
)Ugh fabric cket
anchor d
the over op of
rigid outer
·s as socket
arm
' dy- Rigid plastic Air Suspension strap
hesis shell outer circulation and fastener sewn to
socket - -- space fabric inner socket
·and wrapping over top of
and clipped to Fenestrations in
the Fabric outside of rigid outer outer socket
inner socket - - 1 ~ socket (one for each
that (Iron! opening with side)
adfustable closures Foam rubber
it on and with urinary
xion. drainage rube pass·
through)
: sta-
:k up
over
A B
ift to
Figure 4 Cross section of Carlson and Wood's prosthesis. A, Posterior view. B, Lateral view.
oesis,
21
with nent spinous processes, the ax:illae, l. Independent transfer into and the pressure per square centimeter.
that and the b rachial plexus complex. A out of the socket (Figure 3) Although earlier reports speculated
ranee proximally adjustable socket can be 2. Sufficient stability to permit free about the possibility of interfering
:l for used to accommodate weight loss or use of the upper limbs and with respiration, Grimby and Stener 19
" the gain and allows the amputee to par- wheelchair mobility noted only minimal change in vital
aring tially redistribute the weight-bearing 3. Minimum socket tolerance of capacity with a prosthesis designed to
l that forces to increase comfort. The socket two 4-hour periods daily reduce rib contact. It is usually advis-
ically design must also accommodate the 4. Sufficient weight-bearing pres- able for the amputee to unweight the
s im- ostomy stomas and allow free access sure distribution to prevent skin prosthesis at frequent intervals by
efully necrosis pushing up with the arms, similar to
to these sites for self care. The most
in the 5. Allowance for adequate respira- the technique used by individuals
common design uses rectangular
esin- with paraplegia to avoid skin break-
openings to allow the collection bags tory exchange
r the down.10 Over a period of weeks or
to remain outside the socket, free of 6. No abdominal pain or nausea
orary months, the amputee can gradually
the pressures induced by weight bear- from pressure within the socket
O in-
ing.10·16 Any openings in the socket 7. Prevention of eversion of the co- increase the time spent wearing the
e for
must be carefully limited, or the ab- lostomy and ileal bladder drain- prosthesis until an upright posture in
dominal skin will protrude. In some age bags the device can be tolerated for 8
cases, it is necessary to fashion a latex 8. Easy access to drainage bags for hours or more daily. JO- t 2,15 •16
strap (fastened with Velcro) to cover self care Carlson and Wood 22 emphasize the
rectangular openings and provide 9. Pressure relief over the sternum importance of focusing on basic goals,
trans-
must gentle pressure to reduce the soft- and distal portion of the spine, such as providing for heat dissipation
tissue herniation. With flat drainage even when leaning forward or and protection of skin from shear
g and
trans- bags, it may be possible to omit the back in the socket trauma, that are likely to positively af-
. The colostomy opening, provided that the 10. Acceptable cosmesis fect patient acceptance and success.
e tho- amputee can defecate daily when not 11. Ease in cleansing socket areas in The loss sustained in TLA results in a
>f the wea1ing the prosthesis. 15 contact with the body. 16 decrease of 36% in total skin smface
• need Terz and associates20 have summa- Because of the limited surface area for heat release. When the thorax is
1ferior rized the goals of socket design for available for weight bearing, total contained inside a socket that is not
,romi- the translurnbar amputee as follows: contact is the best approach to reduce permeable to air, the body is left with

586 The Lower Limb
Figure 5 Features of Carlson and Wood's de.sign. A, Flexible fabric inner socket. B, Detail of fabric inner socket showing opening for
stoma site. C, Patient donning the f lexible fabric inner socket. D, Distal relief area. E, Patient demonstrating transfer technique.
Figure
'
mits inc
arm en
for SUS~
fers w:
prosth
Figur(! 6 Pressure transducers for evalua- encum
t ion of socket fit. may bi
rate an
only 45% of its original skin surface to socket.
dissipate heat by convection and evap- reportc
oration. The translumbar amputee allows
also faces potentially significant shea1· fasten,
stress on the remaining thorax. The alJowit
twisting, reaching, and bending mo- behinc
tions involved in everyday activities Bee
can cause significant breakdown, espe- cases .1
Figure 7 A, Dankmeyer and Doshi's endoskeletal prosthesis with a removable socket. recom_:
cially in patients with sensory depriva- Free hip joints, stance-control knees, and SACH feet provide good stability; transverse
tion.3 Therefore, the socket interface is rotation units allow some reciproca l gait. B, The removable socket can be used as a sit-
Each<
ting device. vidual
of critical importance.
perien
Carlson and Wood22 favor a flexi-
ambul
ble fabric inner socket design that is Ambulatory that "the appearance of body normal-
either
flexibly suspended in a rigid frame ity appeared to play an important part
Prostheses polyce
(Figure 4). The design incorporates in motivatil1g them toward seeking a ingll :
features that provide for heat dissipa- Having accomplished the degree of in- Life other than institutionalized hope-
or soli
tion, pressure and shear management, dependence afforded by a sitting pros- lessness and helpless invalidism." Wil-
AltJ
volume change, mobility, and cosme- thesis, some amputees will request liams and Fish 16 concur and report
tings
sis (Figu1·e 5). It uses hydrostatic prosthetic legs for cosmetic purposes that "when the patient was fitted with past6'l
weight-bearing principles similar to or to permit limited ambulation. his final prosthesis, his attitude toward align al
the circumference tensioning used in Davis and associates 12 have reported life changed dramatically... Legs, even is mo1
transfemoral prosthetic socket design. on long-term foJJow-up with two pain a wheelchair, apparently made a dif- versa ti
Pressure transducers can be used to tients who remained ambulatory a11d ference for which there was no substi- skeleta
identify and correct at-risk locations gainfully employed for several years tute...." Although ambulation with corn pc
(Figme 6). following prosthetic fitting and note crutches or a walker is feasible, trans- tion o
American Academy of Orthopaedic Su1geons

Chapter 47: Translumbar Amputation: Prosthetic Management 587
hip joint combinations during gait new mobility, sense of well-being, and
training. ft is also possible to add renewed enthusiasm for life." 13
components sequentially. Initially, The loss of more than half of the
prosthetic feet may be added directly body obviously p resents enormo us
to the socket to create a "stubby" difficulties. However, numerous suc-
prosthesis similar to those used by bi- cessful fittings following TLA attest to
lateral transfemoral amp utees. Length the potential for rehabilitation of in-
can be increased in increments as the di viduals faced with this singularly
patient's balance and strength permit, difficult challenge.
with hip and knee joints added as the
amputee progresses.
Suspension of the prosthesis is References
critical if the stresses of swing-
1. Mackenzie AR, Miller TR, Randall HT:
th ro ugh ambulation are to be toler-
Translumbar amputation for advanced
ated. Over-the-shoulder suspenders
leiomyosarcoma of the prostate. J Ural
g for have proved to be the best option fo r 1967;97:133-136.
this type of prosthesis.6 ' 11 ' 12 ' 14' 16' 22
2. Miller TR, Mackenzie AR, Karasewich
Care must be taken not to pinch any EG: Translumbar ampu tation fo r car-
protruding flesh where the suspend - cinoma of the vagina. Arch Surg 1966;
ers cross the proximal edge of the 93:502-506.
Figure 8 An exoskeletal prosthesis per- socket. 3. Kennedy CS, Miller EB, McLean DC,
mits independent ambulation with fore·
et al: Lumbar amputation or hemicor·
arm crutches. Note the shoulder straps
porectomy for advanced malignancy
for suspension. Summary of the lower half of the body. Surgery
Survival times for translumbar am- 1960;48:357-365.
fers will be more cumbersome with
putees sometimes may be limited, but 4. Smith J, Tuel SM, Meythaler JM, et al:
prosthetic legs attached. Rather t!han Prosthetic management of hemicor·
they have increased steadily as medi-
encumbering the sitting prosthesis, it porectomy patients: New approaches.
cal care has advanced; su rvival for
may be preferable to prescribe a sepa- Arch Phys Med Rehabil 1992;73:
m ore than 20 years has been docu-
rate ambulatory prosthesis with a mew 493-497.
mented. Several reports of retu rn to
socket. Dankmeyer and Doshi 14 have 5. Miller TR, Mackenzie AR, Randall HT:
employment h ave been noted in the
reported an alternative (Figure 7) that Translumbar amputation for advanced
ljterature. 1• 10 • 12 •16 • 19- 22 lt is the mis-
allows the ambulatory prosthesis to cancer: Indications and physiologic
sion of the clinic team to enhance
fasten on top of the sitting device, thus alterations tn four cases. Ann Surg
quality of life during whatever time l 966;164:514- 521.
allowing the amputee to leave the legs
remains fo r the translumbar amp utee.
behind in the chair when transferring. 6. Baker TC, Berkowitz T, Lord GB,
Th.is is accomplished by providing the Hankins H V: Hemicorporectomy. Br J
Because of the small munber of
greatest possible independence and Surg I 970;57:471 -476.
cases reported, it is not possible to
socket. recommend particular components. freedom, including amb ulation to 7. MacKenzie AR: Translumbar amputa-
,sverse Each clinic team must make an indi- whatever degree th e amp utee is capa- tion: The longest survivor. A case up-
1s a sit- ble. The primary factors in the suc- date. Mt Sinai J Med 1995;62:305-307.
vidual determination based on its ex-
perience and judgment. Successful cessful rehabilitation of the trans-
8. Friedmann LW, Marin EL, Park YS:
ambulation has been reported with lumbar amputee are motivation and Hemicorporect0my for functional
)rmal- compliance: the highly motivated in-
either free 14 or lockini 0 hip joints; rehabilitation. Arch Phys Med Rehabil
nt part dividual will succeed despite the dif-
polycentric, stance-control, 14 or lock- 1981;62:83-86.
:king a ing1 1 knees; and either articulated 15 ficulties. 9. Pearlman NW, McShane RH, Jochim-
hope- Aust performed the first successful
or solid ankle-foot mechanisms. 14 •16 sen PR, Sh irazi SS: Hemicorporectomy
1."Wil- Although successful exoskeletal fit- TLA in 1961; the amputee found for intractable decubitus ulcers. Arch
report tings have been reported in the work in a nursing home and survived Surg 1976;1 ll: 1139-1143.
!d with past6 • 10·- 12 , 15 •16 (Figure 8), use of re- until 1980. Aust summarized his long- 10. DeLateur BJ, Lehmann JF, Winters-
toward alignable endoskeletal componen try term experience with this procedure cheid LC, Wolf JA, Fordyce WE, Si-
;s, even is more common now because of its as follows: "Freed of the nonfunction- mons BC: Rehabilitation of the patient
le a dif- versatility and light weight. 14 Endo- ing lower half, the patient is released after hemicorporectomy. Arch Phys
substi- skeletal d esigns with interchangeable from the dead weight holding him Med Rehabil 1969;50:11 - 16.
11 with components permit clinical verifica- down, relieved of his ch ronic infec- 11. Frieden FH, Gertler M, Tosberg W,
·, trans- tion of various foot, ankle, knee, and tion and/or cancer, and experiences a Rusk HA: Rehabilitation after hemi-

588 TheLowerLunb
corporectomy. Arch Phys Med Rehabil 15. Leichtentritt KG: Rehabilitation after after hemicorporectomy. Scand J
1969;50:259-263. hemicorporectomy. Am J Proctol 1972; Rehabii Med 1973;5: 124-129.
12. Davis SW, Chu DS, Yang CJ: Trans- 23:408-413. 20. Terz JJ, Schaffner MJ, Goodkin R, et al:
lum bar amputatio n for nonneoplastic 16. Williams RD, Fish JC: Translumbar Translumbar ampu tation. Cancer
cause: Rehab ilitation and follow-up. amp utation. Cancer 1969;23:416-418. 1990;65:2668-2675.
Arch Phys Med Rehabil 1975;56: l7. Easton JKM, Aust JB, Dawson WJ Jr, 2 1. The most radical procedure. Inter-
359-362. Kottke FJ: Fitting of a prosthesis on a Clin Info Bull 1966; 5:22-23.
13. Aust JB, Page CP: Hemicorporectomy. patient after hemicorporectomy. Arch 22. Carlson JM, Wood SL: A flexible, air-
J Surg Oncol 1985;30:226-230. Phys Med Rehabil 1963;44:335-337. permeable socket prosthesis for bilat-
14. Dankmeyer CH Jr, Dosh i R: Prosthetic 18. Miller TR, Mackenzie AR, Randall HT, eral hip disarticulation and hemicor-
management of adult hemicorporec- Tigner SP: He micorporectomy. Surgery porectomy amputees. J Prosthet Orthot
tomy and bilateral h ip d isarticulation 1966;59:988-993. 1998;10:110-115.
amputees. Ort/wt Prosthet 1981;35: 23. Ferrara BE: Hemicorporectomy: A
I 9. Grimby G, Stener B: Physical perfor-
11-18. collective review. J Surg Oncol
mance and cardiorespiratory function
1990;45:270-278.
Inti
As JJ
team,
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: al: Physical Therapy
Curtis R. Clark, PT
r-
H-
,r-
:hot
Introduction
As members of the rehabilitation with the patient; this is in1portant to pain, discussing how to prevent joint
team, the prosthetist and the physical earn the patient's trust and confi- contracture, describing the functional
therapist often develop a close rela- dence. After introductions, the physi- aspects of the prosthesis, and any
tionship when working with lower cal therapist should explain the tim- other general issues.
limb amputees. The prosthetist is re- ing of events during the rehabilitation
sponsible for creating a prosthesis that process. The unknown can be ex-
will best suit the lifestyle of an individ- tremely frightening to many patients.
Acute Postoperative
ual patient. The physical therapist is These fears can be addressed by ex- Evaluation
involved in several steps of rehabilita- plaining what the future holds and General Factors
tion. Before the patient can be fitted what will be expected of the amputee. The acute postoperative evaluation
with the prosthesis, the physical ther- Having another amputee visit and
consists of several significant compo-
apist helps the amputee become phys- talk with the patient can often assist
nents. First, baseline information
ically prepared for training in use of in this process. To this end, many hos-
must be obtained to establi$h the
the prosthesis. Next, the amputee must pitals have affiliations with local am-
goals of rehabilitation and to formu-
learn how to use and care for the pros- putee support groups with members
late an individualized treatment plan.
thesis. Prosthetic gait training can be who visit prospective or new ampu-
A complete medical history also
the most frustrating, yet rewarding, tees to help them through the healing
process. Visiting amputees should be should be obtained from the patient
phase of rehabilitation for all mem-
carefully screened by appropriate per- or from medical records to supply in-
bers of the team. The amputee must be
sonnel to discern whether they have a formation that may be pertinent to
reeducated in the biomechanics of gait
as he or she learns to use the prosthe- personality suitable for this task. If the rehabilitation program. During
sis. Once success in using the prosthe- they do, they can be matched to the the initial review of the medical
sis is achieved, the amputee can l.ook prospective or new amputee by level record, the physical therapist should
fo rward to resuming a productive life. of amputation, age, gender, and avo- note any history of coronary artery
Finally, the physical therapist should cational interests. Information on disease, angina, myocardial infarc-
introduce the amputee to activities various prostheses or videos showing tion, congestive heart failure, arrhyth-
other than just walking. Although the recreational activities may be useful mias, dyspnea, peripheral vascular
amputee may not be ready to partici- to the patient. A sample prosthesis disease, angioplasty, arterial bypass
pate in recreational activities immedi- may be useful in answering the pa- surgery, diabetes mellitus, hyperten-
ately, providing the names of support tient's questions. At all stages of reha- sion, or renal disease. Any medica-
groups and recreational organizations bilitation, the physical therapist must tions that may influence physical ex-
will enable the amputee to seek in- consider the amount of information ertion or mental status should be
volvement at the appropriate time. that the patient is psychologically pre- recorded.
pared to absorb. The responsibilities Throughout this process, the reha-
of the physical therapist before sur- bilitation team (including the patient)
Preoperative Aspects gery include advising the amputee must view the amputation in a posi-
At the initial contact, the physical about the possibilities of phantom tive light and as a reconstructive
therapist begins to establish rapport limb sensation and phantom limb rather than as a destructive proce-

<lure. The goal is to return the ampu- therapist should assess the patient's ties. The patient must be aware that requi
tee to his or her premorbid lifestyle cognitive potential to perform activi- decreased pain and/or temperature more
and to prevent further adversity such ties such as donning and doffing the and light touch sensation can increase
as delayed healing, falls, or any other prosthesis, regulating prosthetic sock the potential for injury and soft-tissue
medical complications that could plies, bed positioning, provid ing ade- breakdown. Thus, patients should be
have been avoided. In preparation for quate skin care, and ambulating encouraged to monitor changes in
Aco1
prosthetic training, the amputee must safely. If the patient does not have the sensation and use protective strategies
tient'
be immediately taught functional necessary level of cognition, family to avoid injuries or tissue damage.
essar
skills and shown how to care for the members and/or friends should be-
Bed Mobility Lowe
healing residual limb, protect the come involved in the rehabilitation
sound Limb, and avoid physical de- ance
process to help ensure a successful The importance of good bed mobility
conditioning. While the amputee is and
outcome. skills extends beyond simple posi-
still in the hospital, the rehabilitation ass is
tional adjustments for comfort or to
team must emphasize the totality of Range of Motion pute
get in a11d out of bed. These skills are
the rehabilitation process from the The range of motion (ROM) of the that
necessary to maintain correct bed po-
acute stages to completion of pros- upper limbs and the sound lower over
sitioning to prevent contractures and
thetic training. The amputee should initi:
limb as well as the residual limb to avoid excessive fr iction of the bed-
be advised about the entire rehabilita- crut,
should be assessed. Joint contractures sheets against t he suture line or frail
tion process, including the incremen- can hinder the amputee's ability to skin. If the patient is unable to per- long
tal value of each step. Educating the ambulate with a prosthesis, and steps form the skills necessary to maintain com
patient in all aspects may reduce the should be taken to avoid this compli- proper positioning, assistance must diffi
anxiety associated with the uncer- cation. The most common contrac- be provided. As with most patients, cau5
tainty of what lies ahead and enhance tures in the transfemoral amputee are adequate bed mobility is a prerequi- ized
compliance. As mentioned, amputee hip flexion, external rotation, and ab- site skill for more advanced skills such late
support groups, including peer visita- duction. Knee flexion is the most as bed-to-wheelchair transfers. pro,
tion, can be a tremendous asset when commonly observed contracture in
Balance and Coordination Se1
support personnel are well informed transtibial amputees. During assess-
and have views consistent with those ment of ROM, the physical therapist Balance while sitting and standing are The
of the rehabilitation team. should determine whether the patient of major concern when assessing the lish
truly has a fixed contracture or just amputee's ability to maintain the witl
Cardiopulmonary Status muscle tightness from immobility; body's center of mass (COM) over the for
The heart rate and blood pressure of the latter can be corrected within a base of support (BOS). Coordination and
every patient should be closely moni- relatively short period of time. The makes moving easier and helps to re- put
tored both during initial training and presence of the contracture will affect fine motor skills. Both balance and of
throughout the rehabilitation process the initial alignment of the prosthesis. coordination are required for shifting pre·
as the intensity of training increases. This alignment must be adjusted over weight from one limb to another, thus ace,
If the amputee experiences persistent time as t he contracture resolves. improving the potential for an opti- am·
signs and symptoms such as shortness mal gait. After evaluatu1g mental sta- goa
of breath, pallor, diaphoresis, chest Strength tus, ROM, strength, sensation, bal- ces:
pain, headache, or peripheral edema, Functional strength of the major ance, and coordination, the physical tha
further medical evaluation is strongly m uscle groups should be assessed by therapist will have a good indication tre,
recommended. If the patient's car- manual muscle testing of all limbs, in- of the most appropriate initial choice ate
diopulmonary status is a concern, rel- cluding the residual limb and the of assistive device.
atively inexpensive and simple tools trunk. This assessment will help de-
such as pulse oximetry, the Dyspnea termine the patient's potential to per- Transfers A
Index, 1 and the Borg Perceived Exer- form activities involving transfers, Early assessment of a patient's ability F1
tion Scale2 may be used to help mon- wheelchair mobility, and ambulation to make transfers is essential, espe- ln5
itor exertion or to assist th.e amputee with and without the prosthesis. cially when the rehabilitation team is tio
with guidelines for effort during am- planning discharge from the acute (l ;
bulation. Sensation care setting. Many elderly amputees mt
Evaluation of sensation is useful to the can be discharged to home if they are fot
Mental Status patient and physical therapist alike. In- able to complete transfers either inde- sel
An accurate assessment of the pa- sensitivity of the residual and/or pendently or with limited help. If far
tient's mental status can provide in- sound limb will affect proprioceptive moderate to maximum assistance is pl1
sight about the factors likely to affect feedback for balance and single-limb needed for transfers, a facility that of- wl
future prosthetic care. The physical stance, which can lead to gait difficul- fers skilled physical assistance is often fil,

Chapter 48: Physical Therapy 591
tat required until the amputee becomes individual actmt1es of daily living sample size limits any definitive con-
tre more independent. (ADL) and overall functional capac- clusions with regard to correlation of
1se ity, self-rated instruments are more score and step rate. The contention
,ue potential for Ambulation accurate and less biased than ratings that amputees can fairly accurately as-
be With Assistive Devices by observers or reports by caregivers.6 sess their activity level, however, is
in A comprehensive evaluation of the pa- Several subjective instruments have supported by the finding that ampu-
~es tient's potential for ambulation is nec- been specifically designed for amputees with higher AAS scores walked
essary, including strength of the sound tees. Instruments developed for gen- farther. AAS scores also shared a rea-
lower limb and both upper limbs, bal- eral patient populations have also sonable distribution over the popula-
ance on a single limb, coordination, been used with amputees. Perfor- tion group, and the preferred walking
lity and mental status. The selection of an mance-based assessment tools are speed appeared to correlate with the
)Si-
assistive device should match the am- more objective and have the advan- AAS.9
: to putee's level of skill, keeping in mind tage of providing information regard-
are irlg ambulatory ability by determina- Reintegration to Normal
that the device required may change
po- over time. For example, a patient m ay tion of the performance of specific Living Index
and tasks. W ith some of these instru- The Reintegration to Normal Living
initially require a wall<er, but forearm
>ed- ments, the quality of the performance (RNL) Index is designed to assess glo-
crutches may be more beneficial for
frail is graded by the clinician. bal ftmctional status and measure the
long-term use if proper training is
per- Several specific functional outpatient's perception of his or her own
completed. Some patients who have
tain come instruments may be used by cli- capabilities. Many of the 11 items fo-
difficulty ambulating on one ]jmb be-
nust nicians. Each instrument has advan-
cause of obesity, blindness, or gener al- cus on locomotion, self-care needs,
~nts, tages and disadvantages, depending
ized weakness can successfully ambu- perception of self, vocation, social as-
qui- on the i11formation beirlg collected.
late with the additional support pects, and recreational act1v1t1es.
such There appears to be no consensus
provided by a prosthesis. Thus, the RNL Index is a general irldi-
among different rehabilitation centers cator of physical, social, and psycho-
Setting Goals regarding the selection of measure- logical performance. 10
n ment tools used for lower limb ampu-
The rehabilitation team should estab-
g are tees.7 Often, a combination of assess- Prosthetic Profile of the
lish realistic goals that are consistent
gthe ment tools is required to obtain the
with the amputee's desired outcomes Amputee
the appropriate information from an in-
for employment, social interactions, The Prosthetic Profile of the Amputee
:r the dividual amputee or to provide a
and recreational endeavors. Most am- (PPA), a 44-item closed- and semi-
ation comprehensive evaluation of a partic-
putees, regardless of age or the level closed-ended questionnaire, is de-
co re- ular group of amputees. Clinicians
of amputation, can retw·n to their signed to evaluate and assess factors
: and and clinical investigators need to un-
previous lifestyle with only minor potentially related to prosthesis use
ifting derstand the appropriateness of the
·, thus accommodations. 3 -5 Discussing the after discharge from a rehabilitation
amputee's premorbid lifestyle and information that a specific functional
opti- center. Six broad categories are as-
goals early in the rehabilitation pro- outcomes instrument \,vill yield. The
11 sta- sessed, including physical condition,
cess provides valuable information following sections review the most
' bal- type of prosthesis, prosthesis use, en-
that helps to create a personalized common self-report and perfor-
iysical vironment, leisure activities, and gen-
treatment plan that is both appropri- mance-based instruments that have
cation eral information. Multiple subcatego-
ate and motivating. been used with amputees.
choice ries are included within each
category. The PPA reflects the true
Assessment of Self-Report prosthetic profile of the patient after
discharge from a rehabilitation center
Functional Outcome Assessment
ability and helps identify predisposing, en-
espe- Instruments to help determine func-
Instruments ablirlg, and reinforcirlg factors. The
eam is tional outcome can be categorized as A mputee Activity Survey predisposing factors are motivation,
acute ( 1) subjective or self-reported assess- The Amputee Activity Survey (AAS) physical health, and type of rehabili-
tputees ments or (2) more objective per- is a 20-item q uestionnaire that allows tation program. Enabling factors are
hey are formance-based assessments. With a the amputee to describe his or her av- locomotor abilities, health services,
,r inde- self-report instrwnent, the patient, erage daily activity level. 8 A linear re- accessibility to services, and physical
telp. If family member, or clinician com- lationship between total AAS score environment. The reinforcing factors
ance is pletes a questionnaire or survey from and annual step rates of 21 subjects include satisfaction with prosthesis,
that of· Which a test score or descriptive pro- has been observed. No statistical anal- social environment, and social
is often file is generated. For assessments of ysis was completed, and the small interaction. 1 1· 13

Houghton Scale of prostheses and different methods placement to home, supervised care, travelc
The Houghton Scale is a sue-item of care. Responses are recorded along or long-term institutionalization.37·38 as sta:
measure of performance designed to a linear analog scale with four topic Lower Barthel scores indicate difficul- perio<
assess the amount of time and man- headings: prosthetic function, mobil- ties in ascending and descending versui
ner in which the prosthesis is used, ity, psychosocial experience, and well- stairs, walking on level surfaces, self- could
being. 24'25 The results of the PEQ cor- bathing, getting on and off a toilet, healtl
whether a mobility device is required
when walking outside, and the ampu- relate well with those of the PPA and and bowel and bladder controi. 36 thetic
tee's perception of stability while the Houghton Scale. 17 The Barthel Index does not detect
moving over a variety of terrains. One subtle deficits in patients who are Furn
Sickness Impact Profile functioning at a hi.gh level. Therefore, M ee
of the objectives for the Houghton
The Sickness Impact Profile (SIP) is a it may be more applicable for the
Scale is to discriminate between pros- The
comm only used patient-oriented evaluation of self care and mobility of
thesis and wheelchair use in amputees sure
with vascular conditions. 14-17 measure that profiles functional prob- very impaired amputees but is proba- tiona
lems using a 136-item self-report bly not appropriate for assessing unifo
Medical Outcomes Survey questionnaire. Items are divided into prosthesis use and mobility of more sures
Short Form-36 Health the fo llowing 12 categories designed mobile amputees.39 pa tie:
to assess ADL: sleep and rest, emo-
Status Profile who
tional behavior, body care and move-
In theory, patients will inherently ac- ment, home management, mobility, Performance-Based basis
in si
curately report their functional status social interaction, ambulation, alert- Assessment cont1
when p rovided with the appropriate ness behavior, communication, work,
assessment iristrument. 8·12·15·18 One
Instruments mun
recreation and pastimes, and eating.
of the most popular functional out- In addition to each subscale, there are
Electronic Step Counters prov,
come measures is the Medical Out- The use of step counters is not a new who
two domain scores (physical and psy-
comes Su rvey Short Form-36 (MOS concept. Holden and associates 40 impr
chosocial) and one full-scale score of
SF-36) Health Status Profile. 19 This dysfunction. 26 Currently, more than measured the extent of prostl1esis use amp
36-item self-report instrumen t exam- with electronic step counters during sion
140 reports of its application in pa-
ines physical functioning, role limita- tients with more than 40 different dis- inpatient training and documented prov
tions because of physical health and eases and impairments have been amp utee walking habits for 2 years af- score
emotional problems, social function- published. 27-30 SIP scores from am- ter discharge. Continuous monitoring on t
ing, general mental health, pain, putees with diabetes mellitus show provides data pertaining to the actual FIM
health perception, energy, and fa- greater diversity in functional out- use of the prosthesis. In contrast, in- a po
tigue.20 The MOS SF-36 is, to date, come compared with their preopera- formation provided by the patient or bitit:
perhaps the m ost widely applied self- tive fu11ctional abilities than from am- an observer is considered an estimate gan
report instrument used with ampu- putees who do not have d iabetes only. The activity levels correlated grea
tees. This instrument was not specifi- mellitus. In most patients, functional with functional independence are de- asso
cally designed fo r amputees and, abil ities decrease after lower limb am- termined by a questionnaire. An am- the:
therefore, appears to have some weak- putation.31 Thus, lower limb ampu- putee must be able to walk 600 steps a ful i
nesses. 21 For example, MOS SF-36 tees may appear quite disabled in all day to manage independently in a reh~
scores in the physical functioning and disabiJity categories of the SIP scores. single-level house or apartment, with basE
role limitation categories are lower a moderate amow1t of sup port by in 2
among amputees than among normal Barthel Index cLam1·1y mem bers or soc1a. 1 agencies.
. 40
Fu1
age-matched individuals because of The Barthel Index 32 is a useful and As discussed, Day8 used step counters
problems with physical health and popular measure of ADL for patients to validate the AAS. Pr<
pain experienced by amputees. 18•22•23 with a variety of impairments.33·34 The Prosthetic Research Study Net
This performance test originally con- group41 reported that gait styles and Arn
Prosthetic Evaluation per:
sisted of 15 measures but has been re- activity levels of amputees can be an-
Questionnaire duced to 10 measures of self care and alyzed with the Step Activity Monitor, skil
The Prosthetic Evaluation Question- mobility. Either two subscores for a device that continuously records and
naire (PEQ) is a 16-item self-report each measure or one combined score steps during a specific time period. thr,
instrwnent specifically developed for is generated. When administered to These data provide insight beyond ing
amputees with the intent of measur- amputees, the overall index values are that provided by simply counting sic
ing small differences m prosthetic used to assess changes between ad- steps because the time of day for each rep
function and major life domains re- mission and discharge.35•36 The tem- step is also recorded. Therefore, the the
lated to prosthetic function. The PEQ poral change is a good indicator of data from a 2-week period can pro- lidi
compares the effects of different types prognosis and potential discharge vide information concerning distance ho,

are, traveled per day, activity patterns such and potentially informative tool for scoring system requ1rmg very little
;?,38 as stru1ding versus walking time, and clinical use with amputees.4 7 equipment or space. Each item ad-
:ul- periods of day for high step activity dresses specific skills that contribute
Ling versus low step activity. These data Functional Reach Test to overall function, such as sitting
;elf- could assist with the interpretation of T he Functional Reach (FR) test is per- balance, standing balance, dynamic
ilet, health status or the quality of pros- formed by mounting a 48-in (L2-m) balance, coordination, agili ty, power,
thetic rehabilitation . stick on the wall at shoulder height. vestibular input, and vision. When an
:tect The subject stands parallel to the amputee cannot perform a specific
are Functional.Independence stick, raises an arm, and is directed to test item, the clinician can select the
:ore, M easure "Reach as far forward as you can appropriate exercises to address the
the without taking a step!' The distance functional deficit (Figure 1). To d ate,
The Functional Independence Mea-
ty of traveled by the tip of the finger from more than 30,000 reprints of this tool
sure (FIM) was developed by a na-
oba- the start to fi nish position is recorded. have been ordered.
tional task force in 1983 as part of a
Fun ctional reach or the maxin1al safe Health care industry demands for
;sing uniform d ata system. 42 The FIM mea-
nore standing forward reach is considered mechanisms to classify patients for
su res the progress of rehabilitation in
to be a precise, reliable, clinically ac- p urposes of reimbursement have in-
patients with multiple disabilities
cessible, and age-sensitive measw-e of creased tl1e need for valid, reliable
who are being treated on an inpatie nt
balance that approximates COM ex- measures of functional status. The re-
I basis and includes 18 items grouped
cursion and estimates physical frail- liability of the Al\.1P suggests that witl1
in six categories: self-care, sphin cter
ty.48 In nonamputee subjects, the FR proper training caregivers from mul-
control, mobility, locomotion, com-
test can identify the risk of recurrent tiple disciplines can administer the
munication, and social cognition. Im-
test and results will be consistent over
provement varied widely in amputees falls49 and is sensitive to change over
time. 52 In the case of ampu tees, Medi-
who scored low at admission, whereas time. 49' 50 Although standing reach
t new care and managed care providers use
40 improvement appeared to plateau in with amputees has not been reported ,
ates the Durable Medical Equipment Re-
amputees who scored high on admis- Kirby and Chari5 1 observed that sit-
is use gional Carrier K Codes or Medicare
sion and had very little room to im- ting reach in transtibial amputees
uring Functional Classification Levels
prove. Improvement in total FIM with and without a prosthesis and in
ented (MFCL) system to classify the ampu-
scores after rehabilitation depended transfemoral amputees without a
lrS af- tee a nd determine the appropriate
on the ability to ambulate. Th us, the prosthesis did not significantly differ.
toring complexity of prosthetic prescription.
FIM score at admission appears to be Only in the latter group was reach sig-
actual The AMP can differentiate between
a poor predictor of progress in reha- nificantly decreased, probably the re-
st, in- MFCL categories and is strongly re-
bilitation because amputees who be- sult of the ru1terior brim of the socket
ent or lated to other measures of function in
gan at lower functiona l levels showed limiting hip flexion rather than a def-
timate the amputee. In addition, the AMP
greater imp rovements.43 - 45 Leung and icit in balance; this limitation is often
:elated can also predict the distance an am-
associates 16 concurred, reporting that observed with activities such as tying
ire de- putee can walk in 6 minutes, when
the admission FIM score was not use- shoes. administered with or without a pros-
11 am-
steps a ful in predicting successful prosthetic thesis, if the AMP score, age, time af-
rehabilitation in lower Limb amputees
Amputee Mobility
r in a ter amputation, and number of co-
based on their study of prosthesis use Predictor morbidities are entered in a
t, with
ort by in 29 amputees. The Ampu tee Mobility Predictor mathematical prediction equation.
·
1c1es. 40 (Al\.1P) was designed to provide ob- The AMP also shows the potential
Functional Ambulation jective information on an amputee's value of upgrading prosthetic feet and
,unters
Profile potential ability to ambulate, thus as- knees, as well as the effects of higher
Study Nelson 46 developed the Functional sisting a clinician in prescribing the K code category components, on the
les and Ambulation Profile (FAP) as a appropriate prosthetic knee ru1d foot distance an amputee can walk in 6
be an- performance-based test of locomotor components. The AMP can be admin- minutes.
lonitor, skills for a variety of neuromuscular istered to patients with or without the
records and musculoskeletal disorders. 'Ibis use of a prosthesis. Therefore, tl1e The 6-minute Walk Test
period. three-phase test assesses static stand- AMP can be given to an amputee be- Walking speed has long been sug-
beyond ing, dynamic weight shifting, and ba- fore the initial fitting of the prosthesis gested as a performance index be-
:mnting sic ambulation efficiency. Although or to an amputee who has used a cause of its high correlation with oxy-
~or each reported to be a valid instrument, prosthesis for years. The AMP is a gen uptake and sensitivity to the
:,re, the there is no evidence of construct va- 20-item functional measure that is increasing age of subjects.53 Improve-
a11 pro- lidity testing or reliability. The FAP, relatively easy to administer in 15 ment in walking speed is a useful pre-
distance however, appears to be a very quick minutes or less and uses a simple dictor of independent mobility in

AMPUTEE MOBILITY PREDICTOR ASSESSMENT TOOL 12

Initial instructions: Testee is seated in a hard chair with arms. The following maneuvers are tested with or without the use of fl<
the prosthesis. Advise the person of each task or group of tasks prior to performance. Please avoid unnecessary chatter m
throughout the test. Safety First, no task should be performed if either the tester or testee is uncertain of a safe outcome. fr,
The Ril~ih t L'1mb IS:
. PF TT KO TF HD rntact . f L'1mb.is: PF TT KD TF HD rntact
The L et .
1~
1. Sitting Balance: Cannot sit upright independently for 60s =0 ax
Sit forward in a chair with arms Can sit upright independently for 60s =1 UJ
folded across chest for 60s. d1
2. Sitting reach: reach forwards Does not attempt =0 l•
and grasp the ruler. (Tester Cannot grasp or requires arm support =1 (i
holds ruler 12in beyond Reaches forward and successfully grasps item. =2
extended arms midline to the 1
sternum)
a
3. Chair to chair transfer: Cannot do or requires physical assistance =0 ti
2 chairs at 90°. Performs independently, but appears unsteady =1 a
Pt. may choose direction and use Performs independently, appears to be steady and safe =2 b
their upper limbs.
4. Arises from a chair: Unable without help (physical assistance) =0 e
ask pt. to fold arms across chest Able, uses arms/assist device to help =1 .a
and stand. If unable, use arms or Able, without using arms =2
assistive device. t
5. Attempts to arise from a chair. Unable without help (physical assistance) =0 ]
(stopwatch ready): Able requires >l attempt =1
if attempt in no. 4. was without Ab1e to rise one attempt =2
arms then ignore and allow
another attemot without oenaltv
6. Immediate Standing Balance Uns teady (staggers, moves foot, sways ) =0
(first 5s): begin timing Steady using walking aid or other support =l
irnmediatelv. Steady without walker or other support =2
7. Standing Balance (30s) Unsteady =0
(stopwatch ready): for items nos. Steady but uses walking aid or other support =1
7 &8, first attempt is without Standing without support =2
assistive device. If support is
required allow after first attempt
8. Single limb standing balance Non-prosthetic side
(stopwatch ready): time the Uns teady =0
duration of single limb standing Steady but uses walking aid or other support for 30s =l
on both the sound and prosthetic Single-limb standing without support for 30s =2
limb up to 30s.
Grade the quality, not the time. Prosthetic Side
Unsteady =0
Sound side - - - seconds Steady but uses walking aid or other support for 30s =1
Single-limb standing without support for 30s =2
Prosthetic side seconds
9. Standing reach: reach forward Does not attempt =0
and grasp the ruler. (Tester Cannot grasp or requires arm support on assistive device =1
holds ruler 12in beyond Reaches forward and successfully grasps item no support =2 - --
extended arm(s)midUne to the
sternum)
10. Nudge test (subject at Begins to fall =0
maximum position #7): with feet Sta.ggers, grabs, catches self ore uses assistive device =1
as close together as possible, Steady =2
examiner pushes lightly on
subject's sternum with palm of
hand 3 times (toes should rise))
11. Eyes Closed (at maximum Unsteady or grips assistive device =0
position #7): if support is Steady without any use of assistive device = 1
reouired grade as unsteadv.
Copyright ©200 f Advanced Rehabilitation Therapy, Inc. Miami, Florida
Figure 1 Amputee Mobilit y Predictor. (Copyright © Advanced Rehabilitation Therapy, Inc, Miami, FL, 2001 .) Fi~
American Academy of Orthopaedic Su rgeons

12. Picking up objects off the Unable to pick up object and return to standing =0
floor: pick up a pencil off the Performs with some help (table, chair, walking aid etc) = l
floor placed midline 12in in Performs independently (without help from object or =2
front of foot. oerson)
13. Sitting down: ask pt. to fold Unsafe (misjudged distance, falls into chair) =0
arms across chest and sit. If Uses arms, assistive device or not a smooth motion =1
unable, use arm or assistive Safe, smooth motion =2
device.
14. Initiation of gait Any hesitancy or multiple attempts to start =0
(immediately after told to "go") No hesitancy =1
15. Step length and height: walk a. Swing foot Prosthesis Sound
a measured distance of 12ft Does not advance a minimum of 12in =0
twice (up and back). Four scores Advances a minimum of l 2in =1
are required or two scores (a &
b) for each leg.
"Marked deviation" is defined as b. Foot does not completely clear floor without deviation =0
extreme substitute movements to Foot completely clears floor without marked deviation =l
avoid clearing the floor.
b. Foot clearance
16. Step Continuity. Stopping or discontinuity between steps (stop & go gait) =0
Steos annear continuous =l
17. Turning: 180 degree tum Unable to tum, requires intervention to prevent falling =0
when returning to chair. Greater than three steps but completes task without
intervention = l
No more than three continuous steps with or without
assistive aid =2
18. Variable cadence: walk a Unable to vary cadence in a controlled manner =O
distance of 12ft fast as possible Asymmetrical increase in cadence controlled manner =l
safely 4 times. (Speeds may Symmetrical increase in speed in a controlled manner =2
vary from slow to fast and fast to
slow varving cadence.)
19. Stepping over an obstacle: Cannot step over the box =0
place a movable box of 4in in Catches foot, interrupts stride =1
height in the walking oath. Steps over without interruptinJ?: stride =2
20. Stairs (must have at least 2 Ascending
steps): try to go up and down Unsteady, cannot do =0
these stairs without holding on to One step at a time, or must hold on to railing or device =1
the railing. Don• t hesitate to Step over step, does not hold onto the railing or device =2
permit pt. to hold on to rail.
Safety First, if examiner feels Descending
that any risk in involved omit Unsteady, cannot do =0
and score as 0. One step at a time, or must hold on to railing or device =l
Steo over step, does not hold onto the railin2 or device =2
21. Assistive device selection: Bed bound =0
add points for the use of an Wheelchair =1
assistive device if used for two Walker =2
or more items. If testing without Crutches (axillary or forearm) =3
prosthesis use of appropriate Cane (straight or quad) =4
assistive device is mandatorv. None =5
Total Score L41

Abbreviations: PF, partial foot; TT transtibial; KD knee disarticulation; TF transfemoral; HD hip disarticulation; Pt, patient.
Test no prosthesis with prosthesis Observer _ _ _ _ _ _ _ _ ___ Date _ _ _ _ __

Copyright ©2001 Advanced Rehabilitation Therapy, Inc. Miami, Florida
Figure 1 continued

poorly mobile patients. 54 In addition, lower limb amputee. 17' 62 Although more hesitant to m ove the affected rnaint
low gait speed is a significant indica- the 2-minute walk test is a question- limb.63 Rigid dressings, in addition to wheel
tor of falls in the elderly.55 able alternative to the 6-minute walk controlling edema and providing pro- vised
Cooper 56 first introduced the 12- test as a m easm e of cha11ge over time, tection and support, help prevent wheel
minute run performance test with his the correlation to other functional knee flexion contractures and facili- mote
study of 115 US Air Force servicemen. measures was moderate9 and essen- tate greater confidence with bed mo- limit
He concluded that because of its high tially equal to the TUG Test. 17 bility. ambu
correlation with maximal o.xygen IPOPs offer the benefits of rigid
consumption, the 12-minute field dressings and allow ambulation with Tra11
performance test is assumed to be an
Immediate limited weight bearing using an assis- Once
objective measure reflecting the car- Postoperative tive device. These prostheses also af- patie1
diovascular status of an individual Treatment ford the physiologic and psychologi- from
subject. Others have confirmed that cal advantages of early walking with a and t
the 12-minute walk test is a useful,
General Management
limb. Some evidence exists that use of trans·
measurable indication of exercise Principles a strategy that incorporates a pylon tub, ·
tolerance. 57- 59 The goals of postoperative m anage- and foot reduces the number of use ,
Butland and associates 60 con - ment in the new amputee are to re- falls.64 To date, IPOPs have not been temp
ducted 2-, 6-, and 12-minute walk d uce edema, promote healing, prevent associated with an increased munber throt
tests on a group of elderly patients loss of motion, increase cardiovascu- of falls or injury to the healing ampu- trans
and concluded that length of the test lar endurance, and improve strength. tation wound. Providing additional safett'.
was not critical, but a test that takes Functional skills should be intro- support to the resid ual limb in amp u- are r.
less time is easier for both patients duced as early as possible to promote tees with a ne uropathic opposite limb light·
and investigators. Results of all t hree independence in bed mobility, trans- can potentially reduce foot pressm es, allO\o\
tests are reproducible, but the longer fers, and ambulation techniques. Pa- improve balance, and reduce the ef- trans
the test, the greater the variation tient education concerning the self- fort required fo r ambttlation with an wher
among patients within each test. As a ca1·e of the residual and sound limbs assistive device. Removable rigid tient
result, the differences between the 2- can prevent adverse effects such as dressings were originally fabricated amp
and 12-minute tests were greater than contractures, excessive edema, de- from plaster and suspended with a va- initi,
the differences between the 6- and 12- layed healing, or trauma to the sound riety of supracondylar cuff systems. on"
minute tests. Thus, the 6-minute walk limb from overuse. Moreover, each These dressings may now consist of a slide
test was considered a sensible com- member of the rehabilitation team prefabricated copolymer p lastic shell onto
promise. should be aware of the n eed to assist with a soft lining and, in some de- bod!)
The 6-minute walk test is strongly the patient with the psychological ad- signs, will accept a pylon and foot to bane
correlated with other functional mea- j ustment to the lin1b loss. create an !POP. The 1:emovable rigid
sures in lower limb amputees wearin g dressing provides tl1e protection and W'1
a prosthesis. Moreover, the 6-minute Postoperative Dressings other benefits of tl1e classic rigid The
walk test can d istinguish among the The selection of a postoperative dressing with the flexibility of re- mos
five MFCLs. 52 Although this test has dressing varies according to the level moval for wound inspection or bath- tem1
yet to be evaluated in clinical trials of amputation, surgical technique, ing. In addition, socks may be added whe
with amputees, gait speed has been healing requirements, patient compli- or the system tightened for progres- corn
suggested as a useful measure of func- ance, and preference of the physician. sive shrinkage of the residual limb, pare
11
tion and has been used to p lace pa- The five major types used include soft which decreases the time to ambula- con:
tients when discharged from the hos- dressin gs, nonremovable rigid dress- tory discharge from the hospital with put,
pital. 54 Faster ambulation in an ings without an immediate prosthetic a temporary prosthesis. 65 tees
elderly person is a good indicator of attachment, nonremovable rigid as a
independence with regard to ADL. 61 dressings with an immediate postop- Positioning gra1
For transtibia] amp utees, increased erative prosthesis (IPOP), removable When in a supine position, the trans- ma)
walking speed correlates w ith a more rigid dressings, and prefabricated femoral amputee should place a pil- unil
functional lifestyle.9 Walking speed is postoperative devices. Soft dressings low laterally along the residual limb latte
an objective yet inexpensive method are most often used for dysvascular to maintain n eutral rotation with no sisti
of monitoring gait rehabilitation. patients so that regular dressing abduction. If the prone position is Wit]
Shorter walking tests have been changes may be performed and alter- tolerable, then a pillow is placed loss
used for amputees. The Timed Up native wound environments may be under the residual limb to maintain tees
and Go (TUG) Test, for example, has used. The disadvantage of soft dress- hip extension. Transtibial amputees whi
been suggested as a quick and easy ings is that patients frequently de- should avoid knee flexion for pro- put
measure of physical mobility for the crease bed mobility because they are longed periods. A board will help api:

:ted maintain knee extension when in a

o to wheelchair. AU amputees must be ad-
)tO- vised that continual sitting in a
\fent wheelchair without any effort to pro-
cili- mote hip extension may ttltimately
mo- limit hip motion during prosthetic
ambulation (Figure 2).
:igid
with
Transfers A
ssis- Once bed mobility is mastered, the
> af- patient must first learn to transfer
logi- from the bed to a chair or wheelchair
ith a and then progress to more advanced
se of transfer skills such as to the toilet,
,ylon tub, or automobile. In patients who
r of use an immediate postoperative or
been temporary prosthesis, weight bearing
mber through the prosthesis can assist with
npu- transfers and provide additional
ional safety. For transtibial amputees who D
npu- are not candidates for ambulation, a
limb lightweight transfer prosthesis may Figure 2 Proper positioning of the residu al limb. A, Neutral hip rotation with no abduc-
,ures, allow more independent transfers. A tion. B, Hip and knee extension when prone. C, Knee extension when in bed. D, Knee
le ef- transfer prosthesis is typically fit extension w hen sitting. (Copyright © Advanced Rehabilitation Therapy, Inc, Miami, FL,
when the wound is healed and the pa- 1990. Illustrator Frank Angulo.)
th an
rigid tient is ready for training. Bilateral
.cated amputees who are not fitted with an
a va- initial prosthesis transfer in a "head-
,tems. on" manner in which the patient
t of a slides forward from the wheelchair
. shell onto the desired surface by lifting the
Le de- body and pushing forward with both
)Ot to hands (Figure 3).
• rigid
n and W heelchair Propulsion
rigid The primary means of mobility for
)f re- most dysvascular amputees, eith er
bath- temporarily or permanently, is a
Figure 3 Head-on wheelchair-to-mat transfer. (Copyright © Advanced Rehabilitation
added wheelchair. The amount of energy Therapy, Inc, Miami, FL, 7990. Illustrator Frank Angulo.)
ogres- conserved with wheelchair use com-
limb, pared to prosthetic ambulation is
nbula- considerable with some levels of am-
11 with p utation.66•67 Therefore, most ampu- ing the COM anteriorly to prevent rests to enable ease of transfer to or
tees should be taught wheelchair ski lls tipping, which is especially critical from either side of the chair.
as a part of their rehabilitation pro- when ascending ramps or curbs. An
gram. Bilateral and older amput ees alternative method is the addition of Ambulation With Assistive
trans- may use a wheelchair more often than antitipping bars in place of, or in ad-
Devices
. a pil- unilateral and younger ampu tees; the dition to, amputee wheel adapters.
Transtibial amputees also require an All ampu tees need an assistive device
11 lirnb latter are more likely to use other as-
elevated leg rest or board to maintain for times when they choose not to
rith no sistive devices when not ambulating
the knee in extension, thus preventing wear their prosthesis or on occasions
tion is with their prosthesis. Because of the
loss of body weight anteriorly, ampu- prolonged knee flexion and red ucing when they cannot wear their prosthe-
placed
tees are prone to tipping backward the time the residual limb is in a desis secondary to edema, skin irrita-
aintain
1putees while in a standard wheelchair. Am- pendent position, both of which con- tion, or a poor prosthetic fit. Some
>r pro- putee adapters set the wheel axle b ack trol edema. Finally, wheelchaiis amputees require an assistive device
.11 help approximately 2 in (5 cm), thus mov- should be fitted with removable arm- while ambulating with the prosthesis.
Arn.erican Academy of Orthopaedic Surgeons

Although safety is the primary factor More frequent inspection of both cific materials of their socket or lin- actiom
for the selection of an appropriate as- limbs is necessary duri11g the initial ers. In general, laminated plastic, co- silicon,
sistive device, mobility is an impor- months of prosthetic training. A hand polymer plastic, silicone, and other grade,
tant secondary consideration. The mirror may be used to view the poste- composite materials are cleaned with poaller
criteria for selection should include rior aspect of the residual limb and mild soap on a damp cloth. Foam ety of
the following factors: (1) the ability plantar aspect of the foot. Areas of materials are cleansed with rubbing ternati
for unsupported standing balance, redness should be monitored very alcohol. Because some liner materials proble:
(2) the degree of upper limb strength, closely as potential sites for abrasion interact adversely with alcohol, ma.n- pie, a
(3) coordination and skill with the as- or ulceration. Amputees with visual ufacturers' recommendations should protec1
sistive device, and (4) cognition. A impairment should ask a fami ly be followed. After a cleansing agent is liner.
walker is appropriate for amputees member to assist with these daily in- applied, a clean, damp cloth should Lak
with fair to poor balance, strength, spections. If a skin abrasion or ttlcer be used to wipe away any residue. To group
and coordination. If balance and develops, the amputee must under- ensure maxinmm life and safety of suspen
strength are good to normal, forearm stand that in almost all i11Stances, the the prosthesis, patients are reminded lower
crutches may be used for ambulation, prosthesis should not be worn until that routine maintenance of their rash, a
with or without a prosthesis. A quad healing occurs. In some circum- prosthesis should be performed by to mo
cane or straight cane may be selected stances, the patient may wea1· a pro- the prosthetist. among
if balance is questionable while am- tective barrier to avert additional skin mellitt
bulating with a prosthesis. insult while permitting continued use Sock Regulation and The la
of the prosthesis. Without exception, Internal Suspension Sleeve prob le
any injury to the skin should be re- limbs
Patient Education ported and closely followed to avoid
Use
were 1
Skin Care further complications. Sock regulation is of extreme impor- differe
Patients must understand the in1por- tance to prevent excessive vertical author
tance of caring for the residual and Desensitization motion or pistoning between the rean am
sound limbs. The amputee must un- Many amputees experience postoper- sidual limb and the socket. The am- sion sl
derstand that proper care of skin and ative skin hypersensitivity as a result putee should always carry extra socks of de1
scar tissue 011 the residual limb is ex- of disruption of the neuromuscular to be added if pistoning or extreme tho rs
tremely important to prevent break- system and associated edema. Pro- perspiration occurs. A thin nylon tion sl
down during prosthetic gait training, gressive desensitization of the residual sheath applied directly to the residual with d
which would delay rehabilitation and limb is often necessary for restoring limb will help reduce friction at the prob le
lead to further deconditioning. Ap- normal sensation while using wottnd i11terface between the skin and socket. tionaU
propriate ski n care is especially im- compression techniques to reduce Prosthetic socks are available in sev- derma
portant for patients with diabetes edema. Desensitization involves grad- eral thicki1esses (plies), permitting the by YOL
mellitus and/or vascular dysfunction ually introducing stimuli to reduce amputee to obtain the desired fit tendee
because these patients often have an the hyperirritability of the limb. For within the socket. Socks should be ap- longer
increased wound healing time. Pa- example, a soft material such as cot- plied wrinkle-free with the seam hor-
tients must also be taught the differ- ton cloth or lamb's wool is rubbed izontal ru1d on the outside to prevent
Doni
ence between the weight-bearing ar- around the residual limb, followed by skin abrasion . Seamless socks are
eas and pressure-sensitive areas of the available to eliminate this problem. the F
gradually more coarse materials such
residual limb in relation to the design as corduroy. The amputee should Internal suspension sleeves and A wid
and fit of the socket. Amputees progress as quickly as possible to tap- liners are made from a va1·iety of ma- is ava:
should be familiar with the functions ping and massaging with the hand . terial such as silicone, urethane, and tion. E
of the prosthetic components. Eventually, when the suture line has gel composites. Some of the benefits putee
Amputees should be instructed to healed, pressure can be applied to the of these materials include reduced with
visually inspect the residual and residual limb during transfers, mobil- pistoning, better management of un- could
sound limbs on a daily basis or after ity skills, and exercise. These measures stable lin1b volume, improved cosme- 1ary ~
any strenuous activity. The residual will help expedite the ability of the resis, and for some patients with im- wedge
limb is inspected for evidence of any sidual limb to tolerate the prosthesis. pafred band function, easier donning liner.
abnormal pressures from the socket of the prosthesis. Lu1ers not only re- the d
such as areas of persistent redness. In- Care of the Prosthesis duce sheru· forces over scar tissue and suspe1
spection of the sound limb has The socket should be cleaned daily to bony prominences, but they also act socket
greater importance after amputation promote good hygiene and prevent as suspension devices. elastic
because the foot is subject to addi- deterioration of prosthetic materials. Internal suspension sleeves and niug l
tional axial and shear forces to com- The patient should be informed of liners are widely accepted, but some tern al
pensate for prosthetic weight bearing. the best clea11sing agent for the spe- amputees have problems with skin re- Witho

actions from the materials used; some methods of donning each of tl1ese ings and progress to shrinker socks
lin-
silicones and gels are not medical combinations are too numerous to after tllle suture line has healed. Com-
, co-
grade, and, therefore, are not hy- describe here; however, it is impor- pression therapy is a controversial
•ther
poallergenic. Fortunately, a wide vari- tant to emphasize that amputees must topic and each rehabilitation team
with
:oam ety of materials is used, and many al- become proficient in donning and must determine the best course of
,bing
ternatives are available should a doffing their particular prosthesis. treatment for their patients. All com-
problem become evident. For exam- pression technjques m ust be per-
erials
ple, a nylon sheath can be used as a Compression Dressings for formed correctly and consistently to
man-
protective layer beneath the sleeve or prevent constriction of cfrculation,
rnuld the Residual Limb
liner. poor shaping, and edema (Figures 4
ent is Early rigid or semirigid dressings,
Lake and Supan68 surveyed a and 5) . Likewise, compliance is an in-
llOlUd compression wrappings, or shrinker
gro up of amputees who used internal tegral part of tl1e compression pro-
1e. To socks for tl1e residual limb can have
suspension sleeves and reported a gram. All wrappings or shrinker socks
ity of several positive effects: (1) decreased
lower incidence of perspiration, heat should be routinely checked and/or
.inded edema, (2) increased circulation,
rash, and folliculitis among minimally reapplied several times each day. The
their (3) assistance in shaping, (4) provi-
to moderately active amputees and application of a nylon sheath over the
ed by sion of skin protection, (5) reduction
among older amputees with diabetes residual limb before wrapping or
mellitus and/or vascular problems. of redw1dant tissue, (6) amelioration
donning a shrinker sock may reduce
The latter group also reported fewer of phantom lin1b pain/sensation, and shear forces to skin and thus provide
problems with contact dermatitis and (7) desensitization of tl1e residual additional comfort and safety.
?eve limb. Casting transtibial amputees in
limb soreness. Although these results
were not statistically significant, the 0° of knee extension will prevent flex-
ion contracture and provide greater
Issues Pertaining to the
impor- differences were worth noting. The
vertical confidence with early bed mobi li ty.6 3 Sound Limb
authors also reported that the longer
the rean amputee used an internal suspen- For transfemoral amputees, there may The loss of a limb and its substitution
he am- sion sleeve, the greater the likelihood be some value in counteracting con- by a prostlllesis clearly impact gait
:a socks of dermatologic problems. The au- tracture forces with specific compres- biomechanics in most amputees with
extreme thors summarized tl1at silicone suc- sion wrapping techniques. diabetes mellitus. Therefore, when
I nylon tion sleeves appear to offer amputees The use of traditional compression planning treatment for these patients,
residual witlll diabetes mellitus and/or vascular wrapping versus shrinker socks is expert care of the sound limb is criti-
n at the problems a viable alternative to tradi- controversial. Some institutions pre- cal. Preservation of the sound lin1b
i socket. tional suspension with less risk of fer commercial shrinkers because of may permit continued bipedal ambu-
: in sev- dermatologic problems than reported the ease of donning. Advocates of lation by delaying or preventing Joss
tting the by younger, traumatic amputees, who compression wrapping, however, in- of the limb. One reason for concern is
sired fit tended to wear their prostllleses for dicate that compression wrapping that tl1e sound limb compensates for
ld be ap- longer periods of time each day. provides more control over pressure ilie amputee's inability to maintain
eam hor- gradients and tissue shaping.69 equal weight disti·ibution between
) prevent Condie and associates 70 observed that lin1bs resulting in altered gait me-
Donning and Doffing of both transtibial and transfemoral am- chanics. Two known effects on the in-
ocks are
the Prosthesis putees who used a shrinker sock tact limb are altered forces on tl1e
oblem.
eves and A wide variety of suspension systems within 10 days after amputation dem- weight-bearing surfaces of the foot
ty of ma- is available for all levels of amputa- onstrated a significantly reduced time and increased ground-reaction forces
tiane, and tion. For example, tl1e transtibial am- from amputation to prosthetic casting throughout tl1e skeletal structures of
e benefits putee has the option of a hard socket versus those who used wrapping the limb. 7 1• 7 3
: reduced witlll or wiiliout a soft insert that methods. Moreover, even shorter time Amputees witlll diabetes mellitus
:nt of un- could include various forms of auxil- to p rosthetic casting has been ob- may have deviations from normal gait
ed cosme- iary suspension such as a medial served with transtibial amputees re- kinematics that increase vertical and
with im- wedge or internal roll-on locking ceiving semirigid and rigid dress- shear forces in addition to ilie preex-
liner. The transfemoral amputee has ings. 69,70 isting impaired sensation, dysvascular-
:r donning
)t only re- the choice of a nonsuction external Many programs prefer to wait tm- ity, scar tissue, and any foot and/or an-
tissue and suspension or a suction suspension til the sutures or staples have been re- kle deformity of the sound limb.
ey also act socket that can be donned with an moved before using a shrinker sock. Collectively, tlllese factors are associ-
elastic bandage, pull sock, nylon don- For amputees with diabetes mellitus, ated with an approximately 50% inci-
leeves and ning bag, or by wet fit, as well as in- iliis period is often as long as 21 days. dence of amputation in the same or
, but some ternal suspension systems with or However, compression ilierapy can contra1ateral limb witlllin 4 years of the
,ith skin re- Without pin and lock systems. The begin early witl1 wraps or rigid dress- . primary amputation. 74"78 Accord ingly,

No. 3
A A
B A B B A
D c 0 c c 0 0
c
B A B A
A
B A
9
c D
c 0 c
D D
No. 13 No. 14
A A B
B
A
c D c
Figuri
Figure 4 Wrapping of the transtibial residual limb using a figure-of-8 pattern guide. 1. Begin by placing a double-length 4-in elastic dowri
bandage above the kneecap. 2. Wrap around once to secure the bandage comfortably but not too tightly. 3. Continue the bandage arour
around the back and cross to corner D. 4. Bring the bandage around corner D and cross up toward B. 5. Continue around the back 4. Co1
toward A. 6. Wrap the bandage across and down to corner C. 7. Continue to wrap around the end and cover corner D. 8. Move the of th1
bandage up and across the front toward B. 9. Continue to move the bandage across the back and down to corner D. 10. Move up and the t i
across the front to B. 11. Continue to move the bandage across the back to A. 12. Move down and across the front to corner C. dage
13. Continue to wrap across the end and cover corner D. 14. Move the bandage up and across the front to B. 15. Continue to wrap doub
across the back and move down and across to corner C. 16. Move around corner C to corner D and continue up and across the front to band
B. 17. Continue with f igure-of-8 pattern, moving the bandage higher on the residual limb until it is completely covered in a figure-of-8 back
pattern. Remember to apply less pressure as you move up. Complete the wrap by anchoring it with tape. (Copyright© Advanced Re· to co
habilitation Therapy, Inc, Miami, FL, 1989. Illustrator Frank Angulo.) 16. C
on tli
by ar
quet
expert care of the sound foot becomes Strategies to Enhance assist in achieving these goals. This
even more critical after amputation list not only aids the amputee, but Prt
Patient Education
for amputees with diabetes mellitus also provides the clinician with a for- Ex,
Educating amputees about self care
because their chances of achieving mat to prevent overlooking important Ge,1
and home exercise programs is criti-
functional ambulation will decline if points. A checklist designed specifi·
cal to the ultimate outcome of the re- Dec1
they become bilateral amputees. 79 habilitation process. The most diffi- cally for amputees with diabetes mel- endlt
From the onset of rehabilitation, cult task is ensuring that the amputee litus also gives the clinician a system· cul ti
therefore, the patient should be ad- retains the information and complies atic method of educating the amputee ties,
vised about the possible dangers to the with instructions. An itemized check- about preventive care of the insensate less.
opposite limb. list for the amputee to take home can foot (Figure 6). ami;

No. 1 No.2 No. 3 No. 4 No.s No. 6
No.9 No. 10 No. 11 No. 12

No. 7 No. 8
A
A
A
B
B
B
No. 13 No. 14 I No. 15 No. 16 No.1 7
B B
Figure 5 Wrapping of the transfemoral residual limb. 1. Begin by placing a double-length 6-in elastic bandage at letter D and cross
down to corner B. The pressure should be uniform throughout the first eight steps of the wrapping procedure. 2. Wrap the bandage
around corner C and cross up the front to A. 3. Wrap the bandage around the waist w ith the thigh extended and then back to A.
4. Continue wrapping the bandage around the back of the thigh to D. 5. Cross to A and wrap the uppermost part of the inner aspect
of the thigh. 6. Wrap the bandage around the waist to A and then around the back of the thigh to D to cover the upper inner part of
the thigh again. 7. Return toward A, and wrap the bandage down and across to corner C and then re-turn toward A. 8. Wrap the ban-
dage around the back and anchor with tape. This completes part 1 of wrapping with the 6-in bandage. 9. Begin part 2 by placing a
double-length 4-in elastic bandage on the residual limb between corners A and B. This part is the figure-of-8 pattern guide. Wrap the
bandage diagonally around corners Band C. 10. Cross up to A and anchor the wrap. 11. Continue wrapping the bandage around the
back and down to corner C. 12. Wrap up and across to A and then around t he back to D. 13. Continue t he bandage down and across
to cover corners B and C. 14. Continue wrapping the bandage up and across to A. 15. Wrap the bandage around the back to D.
16. Continue down and wrap corners B and C, but wrap slightly .higher than the previous time around. 17. Continue wrapping higher
on the residual limb until the figure-of-8 bandage is completed. Remember to apply less pressure as you move up. Complete the wrap
by anchoring it with tape. Note that the angle between the figure-of-8s should be 80° to 90° at the crossover point to avoid a tourni -
quet effect. (Copyright© Advanced Rehabilitation Therapy, Inc, Miami, Fl, 7989. Illustrator Frank Angulo.)
Preprosthetic general exercise program immediately limb, ambulation with an assistive de-
after surgery, through the prepros- vice before fitting of the prosthesis,
Exercises thetic period, and eventually as part lower and/or upper limb ergometry,
General Conditioning of a daily routine. wheelchair aerobics, swimming,
Decreased general conditioning and The list of possible general aquatic therapy, lower and upper
endurance often contribute to diffi- strengthening and endurance exercise body strengthening at a local fitness
culties in learning functional activi- activities is long. Examples include center, and any sport or recreational
ties, including prosthetic gait. Regard- cuff weights in bed, wheelchair pro- activity of interest. One or more of
less of age or physical condition, pulsion for a predetermined distance, these activities should be selected and
amputees should begin a progressive dynamic exercises for the residual performed to tolerance initially, pro-

g
' b et'IC A mput ee L'Im b Care Ch eck L'ISt
Ph1vsicaI Th eraov D Ia T
Topic Item Date Comoleted b
Skin Insoection E d ucation b
Daily insoection of skin with mirror for difficult to see areas
Attention to bony orominences, between toes and scars
p
Attention to oroblem areas ri
Skin Car e rr
Daily cleansinl?. techniaues mild unscented soao If
Aoolication of Moisturizer w
Avoid hot water $(
Minimize exposure to oersoiration and wet weather
Minimize exoosure extreme heat and cold
a
Foot Ca re p
Toe deforrnitv care (lamb wool between toes)
Clean, drv socks without elastic bands (
Extra deoth shoes with custom molded insertS B
Aooropriate house sliooer or shoes worn at all times in the home
a1
Never walk barefoot esoecially on beaches, hot surface-s or at ni1?.ht in the home
Assistance with nail and callus trimming (if patient is independent use nail file for w
nails and oumice stone for corns & calluses, NO Sh ara Imolements) d
Friction Reduction d
Bed mobility avoid excessive sound limb use P·
Posture and oositioninl?. d
Transfer techniques fc
Eaual wei2ht-bearin2 durinl! standin2 and ambulation p
Ambulation turnin2 techniaues, avoid oivotin2 on sound foot
n
Aoorooriate shoe wear with socks
Residual Limb
ti
Skin insoection (same as above)
Skin care (same as above) ir
Positioninl?. ti
P r osthetic Care fc
Sock regulation (correct olvs, sock aoolication & main drv sock wear)
Prosthetic wear schedule (discuss orocedure if skin lesions aooear)
e,
Daily socket cleansin2 fi
Compression Theraov I d
Wraooin2 or shrinker aoolication techniaues rr
Precautionarv si2ns (oain and swellin2) C<
Ph antom Sensation a nd Pain cl
Awareness and desensitization p,
Suooor t Grou o Particioation
Contact oerson and ohone number
c
Shoe Wear le
Su22est ourchase of 2-3 oairs of orooer shoes for daily rotation of shoes fc
Change shoes with perspiration or when wet and soiled. p
Methods of assessment to insure orooer fit of shoes w
Insoect the inside of shoes dailv for forei2n obiects le
Insnect for excessive wear (sole wear, solit in leather, holes etc..)
IT
Wear drv cotton or wool socks without elastic bands
Wound Car e e1
Always follow orescribed treatment form vour healthcare orofessional U,
Insure that dressing always remain drv and clean tl
Check for drainage of the wound into the sock or shoe, if this occurs have IT
dressin2 chan2ed
e:
Take all prescribed medication and never alter the dosage without consulting your
physician tE
Date item understood or mastered by amputee is-signified in the "Date Completed" column.
(Adapted from Clark and Gailey. From One Step Ahead: an integrated approach to lower extremity prosthetics and
amputee rehabilitation. Course workbook. Advanced Rehabilitation Therapy, Inc 1996 used by permission.)
Figure 6 Sample li mb care checklist for amputees w ith diabetes mellitus. (Copyright© Advanced Rehabilitation Therapy, Inc, Miami, v
FL, 1998.)

gressing to 1 hour or more each day. namic exercises requ ire little in the prosthetic control and help the am-
The advantages of activity extend well way of equipment. A towel roll or step putee respond to tl1e demands of
beyond improving the chances of am- stool is all that is required. In addi- walking.73 When possi~le, these exer-
bulating well with a prosthesis. Am- tion to increasing strength, these exercises should be performed in a closed
putees have the opportunity to expe- cises offer benefits such as desensiti- kinetic chain posture (Figures 8 and
rience and enjoy activities that they zation and increasing bed mobility 9). Amputees who have access to iso-
rnay have thought were not possible. and joint ROM. They are relatively tonic and isokinetic strengthening
If the amputee experiences difficulties easy to learn and can be performed equipment can benefit from using
while still admitted to the hospital, re- independently, permitting the physi- this equipment with a few modifica-
sources such as a physical therapist or cal therapist to spend patient contact tions in positioning on the machines.
a fellow amputee who has mastered a time on more advanced skills. Incor-
particular activity will be available. porating isometric contractions at the Range of Motion
peak of the isotonic movement will Prevention of decreased ROM and
Cardiovascular Endurance help to maximize increases in contractures is a major concern in the
Because the average general physical strength. A 10-second contraction fol- rehabilitation of amputees. Limited
and cardiac condition of amputees lowed by 10 seconds of relaxation for ROM often results in difficulties with
with vascular conditions is poor, car- 10 repetitions gives the patient an eas- prosthetic fit, gait deviations, or the
diovascular endurance training can ily remembered mnemonic: the "rule ability to ambulate with a prosthesis
directly affect functional walking ca- of ten ." The rationale behind a 10- altogether. The best way to prevent
pabilities, particularly distance and second contraction is that a maximal loss of joint mobility and ensure full
the type of assistive device required isometric contraction can be main- ROM in the joints is to remain active.
,
for walking. 80-82 Aerobic training im- tained for 6 seconds; however, there is Unfortunately, not all amputees have
proves overall ambulation capabilities a 2-second rise time and a 2-second this option; therefore, proper limb
regardless of the level of amputa- fall time. Thus, a 2-second rise plus a positioning must be maintained long
tion. 83 6-second maximal contraction plus a after amputation, especially in seden-
Aerobic training typically begins 2-second fall equals a total time of 10
tary amputees (Figure 2). Amputees
immediately after surgery as the pa- seconds.89
who have already lost ROM may ben-
tient is increasing his or her tolerance All amputees should consider per-
efit from traditional physical therapy
for sitting. Training continues with forming abdominaJ and back extensor
such as passive ROM, contract-relax
early ambulation. Improving aerobic strengthening exercises to maintain
stretching, soft-tissue mobilization,
fitness should be incorporated into trunk strength, decrease the risk of
myofascial techniques, joint mobiliza-
the rehabilitation program and re- back pain, and assist in the reduction
tion, and other methods that promote
main a part of the amputee's general of gait deviations associated with the
increased ROM.
conditioning program long after dis- trunk. Figure 7 shows a basic dynamic
charge. Initially, most amputees can strength training program for trans- Functional Activities
perform upper limb ergometry. 84 - 86 femoral and transtibial amputees.90
Once balance and strength return, Encouraging activity as soon as possi-
Strengthening exercises should be
lower limb ergometry may be per- performed in multiple planes of mo- ble after amputation helps speed re-
formed with the sound limb first, tion over tinle. For example, if a trans- covery in several ways. First, it offsets
progressing to the prostl1etic limb tibial amputee were to strengthen just the negative effects of immobility by
when appropriate. As the amputee's the knee flexors and extensors, which promoting joint movement, muscle
level of fitness inlproves, other equip- primarily control movement in the activity, and increased circulation.
ment such as treadmills, stair climb- sagittal plane, control of the knee in Second, it helps amputees to reestab-
ers, and rowing machines may be the frontal and transverse planes lish their independence, which may
used . Remember that an1putees enjoy would not be achieved. With a be perceived as threatened because of
the same activities as nonamputees, strengthening program that focuses the loss of the limb. Finally, the psy-
making swimming and walking the on all three planes of motion, how- chological advantages of activity and
exercises of choice for general fitness, ever, the ability to control excessive independence have an impact on pa-
regardless of age or athletic ability.87 movement when walking in any di- tient motivation throughout rehabili-
rection or on uneven terrain will im- tation .
St rengthening prove stability and confidence in con-
Eisert and Tester88 first described dy- trol of the prosthesis. Exercises that
Unsupported Standing
namic exercises fo r the residual limb promote strengthening in multiple Balance
in 1954. Since then, their antigravity planes while incorporating rapid In preparation for ambulation with-
exercises have become the most fa - movements with concentric and ec- out a prosthesis, all amputees must
vored method of strengthening. Dy- centric con tractions can assist with learn to compensate for loss of the

we
PROSTHETIC REHABILITATION PROGRAM EXERCISES an
!in
br1
bu
011
~ - fid
bu
ho
lev
~
ab:
to
- wa
vie
A B wi·
au
SUJ
tie
ba:
ha
sh1
de
bo
ba
ski
ge1
pit
an
c D E be
to
I po
wi:
pe,
sid
1n1
la
crt
arr
G sin
Sta
wi·
lb sin
th,
fo(
F
te~
lin
H taj
a~
add
Figure 7 Strengthening exercises for the residual limb. A, Hip extension. B, Hip abduction. c. Hip f lexion. D, Back extension. E, Hip dif
duction. F, Bridging. G, Sit-ups. H, Knee extension. la, Knee flexion, on table. lb, Knee flexion, leg over table. (Copyright © Advance 111
Rehabilitation Therapy, Inc, Miami, FL, 1989. Illustrator Frank Angulo.) co

weight of the amputated limb by bal-

ancing their COM over the sound
Jirnb. Although this habit must be
broken when learning prosthetic am-
bulation, balance on a single limb
must be learned initially to build con-
fidence for stand-pivot t ransfers, am-
bulation with assistive devices, and
hopping, depending on the amputee's
level of skill. An amputee must be
able to balance for at least 0.5 second
to allow for the smooth and safe for-
ward progression of an assistive de-
vice during ambulation.
One method of progression begins
with the amputee standing in the par-
allel bars while using both hands for
support90 (Figure 10). Once the pa-
tient is able to stand in the parallel
bars using both arms for support, the
hand on the side of the amputation
should be removed from the bars. In-1
dependent balance is achieved when
both hands can be removed from the
bars. To improve balance and righting
skills, the patient is challenged by Figure 8 Ball rolls exercise. A, Place a tennis ball under the sound limb and hold onto
an immovable object. B, Roll the ball quickly 10 to 15 t imes forward and backward and
gently tapping the shoulders in multi- then side-to-side, followed by clockwise and counterclockwise movements. (Copyright©
ple directions or by tossing a ball back Advanced Rehabilitation Therapy, Inc, Miami, FL, 1994. Illustrator Frank Angulo.)
and fo rth. 90 Enough time is allowed
between taps or throws for the patient
to regain a comfortable standing
posture. Once confidence is gained
within the parallel bars, the patient is
permitted to practice these skills out-
side of the bars, eventually progress-
ing to hopping activities.
Pregait Training
Balance and Coordination
After the loss of a lower limb, the de-
crease in body weight will alter the
amputee's COM. To maintain the
single-limb balance necessary during
stance without a prosthesis, ambulate
with an assistive device, or hop on a
single limb, the amputee must shift
the COM over the BOS, which is the
foot of the sound limb. As the ampu-
tee becomes more secure in single-
lirnb support, reorientation to main- Figure 9 Resisted elastic kicks exercise. Secure one end of a rubber tubing band to a
taining the COM over both the sound sturdy table leg and the other end around the sound ankle. Holding onto a chair, the
amputee moves far enough away from t he table so that the rubber tubing is slightly
and prosthetic limbs becomes more
stretched. The amputee then (1) kicks the leg back, w hile facing the table; (2) kicks
difficult. Ultimately, the amputee across the prosthetic limb and (3) away from the prosthetic limb while standing side-
must also learn to maintain his or her ways to the table (A); and (4) kicks forward, w ith his or her back to the table (B). (Copy-
COM and entire body weight ~ver the right© Advanced Rehabilitation Therapy, Inc, Miami, FL, 1994. Illustrator Frank Angulo.)

prosthesis before and during ambula- the

A tion should be emphasized. uni<
Balance on the prosthetic limb tati<
while advancing the sound limb the
should be practiced in a controlled of
manner so that when required in a join
be,
dynamic situation such as walking,
gait
the amputee can do this with rela-
put,
tively little difficulty. The stool step-
pro,
ping exercise is an excellent method
the
for learning this skill. The amputee
suit
stands in the parallel bars, or between
me1
two chairs when training at home,
dee
with the sound limb in front of a 4- cloi
to 8-in stool (or block); the height de- hur
pends on level of ability. The patient
is then asked to step slowly onto the Pe
stool with the sound limb while using Th<
bilateral upper limb support on the boc
parallel bars. To increase these (1)
Figure 10 A. Standing balance using the parallel bars. B, Dynamic balance activities weight-bearing skills, the patient is shil
within the parallel bars. (Copyright© Advanced Rehabilitation Therapy, Inc, Miami, FL, asked to remove the hand on the (4)
1989. Illustrator Frank Angulo.) sound side from the bars. Eventually, can
both hands are removed from the res1
bars. Initially, the speed of the sound cor
prosthesis. Once comfortable with weight bearing into the prosthesis. In- leg will increase when upper limb SU[
bearing weight equally on both limbs, creased weight bearing will be a direct support is removed. 93 With practice, sto
the amputee can begin to develop result of improved COM displace- the movement will become slower joi1
confidence with i11dependent stand- ment and will establish a firm foun- and more controlled, thus promoting of
ing and eventually with ambulation. dation for weight shifting during am- increased weight bearing on the pros- pla
ihesis (Figure 12). the
bulation.
Orientation to COM and The amputee's walking speed and ga·
BOS Standing on a Single Limb the ability to control sound limb ad-
vancement are directly related to the rh)
Orientation of the COM over the Bearing weight on the prosthesis is
ability to control prosthetic limb boi
BOS is necessary to maintain balance; one of the most difficult challenges
facing the physical therapist and am- stance.94•95 The following three fac· CO!
thus the amputee must become famil- 10'
putee alike. Without the ability to tors may help the amputee achieve
iar with these terms and their rela- anc
maintain full single-limb weight bear- adequate balance over the prosthetic
tionship. The COM is 2 inches (5 cm) Sta
ing and balance for an adequate limb: (1) control of the musculature
anterior to the second sacral vertebra. ca1
amount of time (0.5 second mini- of the amputated side; (2) use of the
Although the average person stands th(
mum), the amputee will exhibit sev- available sensation at the residual
with his or her feet 2 to 4 inches (5 to fer
eral gait deviations including (1 ) de- limb/socket interface; and (3) visual·
10 cm) apart, both the COM and the ac
ization of the prosthetic foot and its
BOS vary according to height. 91 •92 creased stance time on the prosthetic re
side, (2) shortened stride length on relationship to the ground. New am·
Various methods of proprioceptive en-
and visual feedback may be used to the sound side, or (3) lateral trunk putees will initially have difficulty in
(b1
help the amputee to maximize the bending over the prosthetic limb. understanding these concepts but will
ge:
attain a greater appreciation of them
displacement of the COM over the Strength, balance, and coordination pH
BOS. The amputee must learn to dis- are the primary physical factors influ- with time. bl)
place the COM forward and back- encing single-limb stance on a pros- m
ward, as well · as from side to side93 thesis. Fear, pain, and lack of confi- Gait Training Skills
(Figure 11). These exercises vary little dence in the prosthesis must be
Sound and Prosthetic Limb
from traditional exercises for shifting considered when an an1putee appears
weight, with the exception that the to be extremely reluctant to bear Training
emphasis is placed on the movement weight on the prosthesis. Adequate Another factor in adjusting to lower
of the COM over the BOS rather than weight bearing and balance on the limb amputation is the restoration of

the gait biomechanics that were

unjque to the amputee before ampu- A
tation. That is to say, not everyone has
the same gait pattern. The restoration
of full function to the remaining
joints of the amputated limb should
be a goal of gait training. Prosthetic
aait
o
training should not alter the am-
putee's gait mechanics to suit the
prosthesis; rather, the mechanics of
the prosthesis should be designed to
suit the gait of the amputee. Develop-
ments in prosthetics during the past
decade have provided prostheses that
closely replicate the mechanics of the
human leg.
Pelvic Motions
B
The pelvis moves as a unit with the
body's COM in four directions:
(1) vertical displacement, (2) lateral
shifting, (3) horizontal tilting, and
(4) transverse rotation. Each motion•
can directly affect the amputee's gait,
resulting in gait deviations with a
concomitant increase in energy con-
sumption during ambulation. If re-
storing function to the remaining
joints of the amputated limb is a goal
of gait training, then pelvic motion
plays a decisive role in determining
the final outcome of the amputee's
gait pattern.
Vertical displacement is simply the
rhythmic up and down motion of the Figure 11 M ethods to help the amputee maximize diisplacement of the COM over the
body's COM. To reduce the metabolic BOS. A, Latera l shifting of weight and balance orientation. 8, Forward and backward
cost of walking, the knee must flex weight shifting and balance orientation. (Copyright© .Advanced Rehabilitation Therapy,
10° to 15° during loading response Inc, Miami, Fl, 1989.)
and be fully extended during mid-
stance.96•97 The transtibial amputee (5 to 10 cm), depending on the height side. More frequently, this is observed
can flex and extend the knee during in transfemoral amputees; however,
of the amputee. Amputees spend an
the stance phase of gait. The trans-
inordinate amount of time in single this altered BOS may also be seen
femoral amputee, unfortunately, is at
limb stance on the sound limb, such with transtibial amputees.
a disadvantage because the knee must
as when they are on crutches, hop- Horizontal tilt of the pelvis is nor-
remain in extension throughout the
ping without the prosthesis, or during mal up to 5°, and any tilt greater than
entire stance phase to avoid collapse
(buckling) (Figure 13). Evidence sug- relaxed standing. Therefore, they are 5° is considered excessive. Usually, ex-
gests that the contribution of stance adept at maintaining COM over the cessive horizontal tilt of the pelvis is
phase knee flexion does not apprecia- sound limb and have a habit of cross- directly related to weak hip abductor
bly alter the arnow1t of vertical move- ing midline with the sound foot. musculature, specifically the gluteus
ment during n ormal walking.98•99 Thus, adequate space for the pros- medius. Maintenance of the residual
Lateral shift occurs as the pelvis thetic limb to follow a natural line of femur in adduction via the socket
shifts from side to side approximately progression is not available. The re- theoretically places the gluteus me-
2 in (5 cm) (Figure 14). The amount sult is an abducted or circumducted dius at the optimal length-to-tension
of lateral shift is determined by the gait with greater lateral displacement ratio. If the limb is abducted, how-
width of the BOS, which is 2·to 4 in of the pelvis toward the prosthetic ever, the muscle shortens in th at posi-

vanced gait training exercises are of- e

fered to help the amputee negotiate a t
variety of environmental conditions s
that require multidirectional move-
ments and superior dynamic balance. t
The time required to progress t
through the sequence and overall out- v
come varies, based on the amputee's t
physical ability, diagnosis, and moti- t
vation. The following sequence of f,
steps is adapted from the Prosthetic t
Gait Training Program:93 c
1. Dynamic residual limb exercises c
are used to strengthen muscles (see s
Preprosthetic Exercises). c
2. Proprioceptive neuromuscular f,
facilitation, Feldenkrais techniques, or c
any other movement awareness tech- a
;
niques may be initiated for trunk, pel- v
: vic, and limb reeducation patterns.
:
These exercises encourage rotational
: : t
:
.. ' motions and promote independent
: [
..
; ; : movements of the trunk, pelvic gir-
.,,
, .. t
dle, and limbs.
3. Pregait training exercises are ini- r
Figure 12 Stool stepping exercise. (Copyright © Advanced Rehabilitation Therapy, Inc, v
tiated (see Pregait Training).
Miami, Fl, 1989. Illustrator Frank Angulo.) [
4. Sound limb stepping within the
t
parallel bars is initiated (Figure 16).
s
tion and is unable to function prop- of trunk, pelvic, and limb biomechan- The amputee steps forward and back-
c
erly. The result is a Trendelenburg ics can be taught to the amputee in a ward, heel rise to heel strike, with both
limp, or compensatory gluteus me- systematic way. First, independent hands on the parallel bars. The pur·
dius gait, in which the trunk leans lat- movements of the various joint and pose of this activity is to familiarize
erally over the prosthetic limb in an muscle groups are developed. Second, the amputee and the physical therapist
attempt to maintain the pelvis in a these independent movements are with the gait mechanics of the sound
s
horizontal position. incorporated into the functional limb without having to be concerned
Transverse rotation of the pelvis movement patterns of the gait cycle. about weight bearing and balance on "
11
occurs around the longitudinal axis Finally, all component movement pat- the prosthetic limb. This activity also
approximately 5° to 10° forward and terns are integrated to produce a affords the physical therapist an op-
backward (Figure 15). This rotation smooth, normalized gait. portunity to palpate the anterior su·
assists in shifting tJ1e body's COM perior iliac spines (ASISs) to gain a
from one side to the other and helps Sample Functional feeling for the amputee's pelvic mo-
to initiate the 30° of knee flexion dur- Prosthetic Training Program tion, which in most cases is close to
ing toe-off, which is necessary to In 1989, Gailey and Gailey93 intro- normal for the amputee.
achieve 60° of knee flexion during the duced a functional prosthetic training 5. Prosthetic limb stepping within
acceleration phase of swing. Knee program that offers a systematic way the parallel bars is similar to sound
flex:ion during preswing is created by to establish static and dynamic stabil- limb stepping, except that the pros·
other influences as weU, including ity and prom ote single-limb standing thetic limb is used. As the physical
plantar flexion of the foot, horizontal balance over the prosthetic limb. therapist palpates the ASISs, a poste·
tilt of the pelvis, and gravity. No pros- Once the amputee has attained a basic rior rotation of the pelvis may be ob·
thetic foot permits active plantar flex- level of strength and balance, resistive served in some patients. This poste·
ion, and horizontal dip greater than gait training techniques are imple- rior rotation is often a result of the
5° is abnormal. Therefore, restoration mented to reeducate ilie amputee in amputee's attempt to kick tJ1e pros-
of transverse rotation of the pelvis be- the normal gait movements necessary thesis forward with the residual limb,
comes of great importance to obtain to maximize prosthetic performance as it would when kicking a football.
sufficient knee flexion. Normalization and promote economy of gait. Ad- The amputee should feel the differ·

ence between the pelvic motion on

A
the prosthetic side and the sound
side.
6. To restore the correct pelvic mo-
tion, the amputee places the pros-
thetic limb behind the sound limb
while holding the parallel bars with
both hands (Figure 17). The physical
therapist then blocks the prosthetic
foot to prevent forward movement of
the prosthesis. Rhythmic initiation is
used, giving the amputee the feeli ng
of rotating the pelvis forward as pas-
sive flexion of the prosthetic knee oc- B
curs. As the amputee becomes com-
fortable with the motion, he or she
can begin to move the pelvis actively
and progress to resistive movements
when deemed appropriate by the
physical therapist.
7. Once the amputee and physical
therapist are satisfied with the pelvic
motions, the swing phase of gait ca~
be taught (Figme 18). The amputee is
ready to step forward and backward
with the prosthetic limb. The pelvic
motions should be monitored so that
the line of progression of the prosthe- Figure 13 Vertical d isplacement of COM in a nonamputee (A) and in a transfemoral am-
sis remains constant without circum- putee (B). (Copyright© Advanced Rehabilitation Therapy, Inc, Miami, FL, 1989. Illustra-
tor Frank Angulo.)
duction and the heel contact occurs
within the boundaries of the BOS. As
the amputee improves, the sound side
and eventually both hands are re-
leased from the parallel bars. There
should be lfrtle if any loss of efficiency
with the motion; however, if there is
loss of efficiency, the amputee may re-
vert to the previous phase of training.
8. The next step is a return to
sound limb stepping with both hands
on the parallel bars. The physical
therapist will determine if the me-
chanics are correct and that the sound
foot is not crossing the midline with
heel contact. When ready, the ampu-
tee will remove ·the hand on the
sound side from the parallel bars. At
this time, there may be an increase in
the speed of the step, a decrease in Figure 14 Lateral displacement of t he body's COM is 5 cm, and horizontal tilt of t he
pelvis is approximately 5°. (Copyright © Advanced Rehabilitation Therapy, Inc, Miami,
step length, and/or lateral leaning of
FL, 1989. Illustrator Frank Angulo.)
the trunk. These changes may occur
as a direct result of the inability to
bear weight or balance over the pros-
thesis. The amputee is verbally cued (see Pregait Training). After this skill practiced until single-limb balance
to remember the skHls learned while is perfected, sound limb stepping over the prosthetic leg is sufficiently
performing the stool stepping exercise without any hand support may be mastered (Figure 19).

therapist may or may not continue to siV(

provide proprioceptive input to the tee
pelvis. As the amputee begins to am- sta:
bulate independently, verbal cueing ha I
may be necessary as a reminder to As
keep the sound foot away from the the
midline to maintain the proper BOS. W1
Maintenance of equal stride length the
may not be immediately forthcoming aw
because many amputees have a ten- COl
dency to take a lo nger step with the ca1

prosthetic limb than with the sound mt
limb. When adequate weight bearing
through the prosthetic limb has been pe:
Figure 15 Transverse rotation of the pelvis is approximately s• anterior and posterior to achieved, the amputee should begin Wl
the neutral position. (Copyright © Advanced Rehabilitation Therapy, Inc, Miami, FL, to take longer steps with the sound riv
1989. Illustrator Frank Angulo.) rel
Limb and slightly shorter steps with
the prosthetic limb. This principle ca1
also applies when increasing the ca- ini
dence. As an amputee increases the th:
speed of walking, a longer step is of- as
ten taken on the prosthetic limb in in:
compensation, thus increasing the q
asymmetry. By simply having the am- eq
putee take a longer step with the
sound limb and a moderate step with in
the prosthetic limb, increased speed
of gait is accomplished without in-
creased asymmetry.
11. Trunk rotation and arm swing
are the final components of restoring ga
ihe biomechanics of gait. During lo-
comotion, the trunk and upper limbs
rotate opposite to the pelvic girdle
and lower limbs. Trunk rotation is
necessary for balance, momentum,
and symmetry of gait. Many ampu-
tees have decreased trunk rotation
Figure 16 Sound limb stepping is designed to orient the amputee to gait biomechanics. and arm swing, especially on the 11
(Copyright © Advanced Rehabilitation Therapy, Inc, Miami, FL, 1990. Illustrator Frank prosthetic side, which may be the re·
Angulo.)
sult of fear of displacing their COM
too far forward or backward over the
c:
prosthesis. Normal cadence is 90 to
9. When each of these individual tance through the hips, providing f
120 steps per minute or 67 to 82
skills has been performed to an ac- proprioceptive feedback to the pelvis a
meters per minute (2.5 to 3.0 miles
ceptable level of competency, the am- and the involved musculature of the 0
per hour).91 Arm swing provides bal-
putee is ready to combine them and lower limb. fi
ance, momentum, and symmetry of
begin walking with the prosthesis. 10. When both the physical thera- d
gait, and it is directly influenced by
ti
Initially, the amputee will walk with.in pist and the amputee are comfortable the speed of ambulation. 92 As walking
the parallel bars, facing the physical with the gait demonstrated within the 8
speed accelerates, arm swing increases
therapist. The physical therapist's parallel bars, the amputee begins to permit a more efficient gait. There·
ti
bands are placed on the amputee's practicing outside the bars, with the fore , amputees who walk at slower
l
ASISs, and the amputee is holding amputee initially using the physical speeds will initially have a diminis~ed
onto the parallel bars. As the amputee therapist's shoulders as support and arm swing. Restoring trunk rotation
ambulates within the parallel bars, the progressing to both hands free when and arm swing is easily accomplished
physical therapist applies slight resis- appropriate (Figure 20) . The physical by using rhythmic initiation or pas·

sively cueing the trunk as the ampu-

tee walks. The physical therapist
stands behind the amputee with one
hand on either shoulder (Figure 21).
As the amputee walks, the physical
therapist gently rotates the trunk.
When the left leg is moved forward,
the right shoulder is rotated forward
and vice versa. Once amputees feel
comfortable with the motion, they
can actively incorporate this move-
ment into their gait.
Amputees who will be totally inde-
pendent arobulators and those who
will require an assistive device can de-
rive some benefit from this systematic
rehabilitation program. Most patients
can progress to the point of ambulat-
ing outside of the parallel bars. At Figure 17 Rhythmic initiation is designed to promote transverse rotation of t he pelvis.
(Copyright© Advanced Rehabilitation Therapy, Inc, Miami, FL, 1990. Illustrator Frank
that time, the amputee must use an Angulo.)
assistive device to practice ambulat-
ing. Maintaining pelvic rotation, ade-
quate BOS, equal stance time, ancP
equal stride length all have a direct
influence on the energy cost of walk-
ing. Trunk rotation will be absent in
amputees using a walker as an assis-
tive device. Those ambulating with
crutches or a cane should be able to
incorporate trunk rotation into their
gait.
Variations for Syme

and Hip
Disarticu lation
Patients
The duration and degree of prosthetic
training is unique to each amputee.
Many factors influence training, such Figure 18 The swing phase of gait. (Copyright© Advanced Rehabilitation Therapy, Inc,
as age, general health, motivation, and Miami, FL, 1990. lflustrator Frank Angulo.)
cause and level of amputation. Pa-
tients who have had a Syme ankle dis-
articulation have a major advantage
and other gait skills, they may require tion amputee must learn the same
over transtibial amputees in that the
practice to achieve equal stride length prosthetic gait skills as a transfemoral
former are able to bear some weight
distally. The ability to bear weight dis- and stance time. Patients who have amputee. Those who have undergone
tally provides better kinesthetic feed- had a knee disarticulation also have hip disarticulation and transpelvic
back for placement of the prosthetic several advantages over transfemoral amputees also need to master control
foot. Because of tl1is capability and amputees, such as a longer lever arm, of a mechanical hip joint as well as
the length of the lever arm, these am- enhanced muscular control, in1proved the knee joint and foot/ankle assem-
putees require minimal prosthetic kinesthetic feedback, and greater dis- bly. The gait training procedures are
gait training. Although patients who tal end weight bearing. Although essentially the same as for the trans-
have had a Syme procedure can these advantages may decrease reha- femoral amputee; however, in some
progress rapidly with weight· shifting bilitation time, the knee disarticula- patients the mechanical hip joint may

p1
sa
Si
Tl
fo
Iii
st
tt.
SC
st
O'
t(
tl:
Cl
d
t<
li
e,
SI
Figure 20 Once correct biomechanics are ii
established w ithin t he parallel bars, resis-
tl
t ive gait training may be performed in an
Figure 19 Sound side stepping to promote equal stride length of the sound limb and open area to build confidence and inde- tl
stance time of t he prosthetic limb. (Copyright © Advanced Rehabilitation Therapy, Inc, pendent gait skills. (Copyright © Ad· SI
Miami, FL, 1990. Illustrator Frank Angulo.) vanced Rehabilitation Therapy, Inc, Mi-
ami, FL, 1990. Illustrator Frank Angulo.) c
0
require a slight vaulting action for the c

foot to cleru· the ground. a
t
t
~dvanced Gait s
Training Activities t
Stairs
Ascending and descending stairs is
most safely and comfortably per-
formed one step at a time (step-by-
step) . Using purely mechanical
prostheses, only a few exceptional
transfemoral amputees can descend
stairs step-over-step, or by the "jack-
knifing" method. A few very strong
lower limb amputees can ascend stairs
step-over-step. Most transtibial am-
putees have the option of either
method. Transpelvic amputees or
Figure 21 Passive trunk rotation w ill assist in restoring arm swing for improved balance, those who have had a hip disarticula-
symmetry of gait, and momentum. (Copyright © Advanced Rehabilitation Therapy, Inc, tion are limited to the step-by-step
Miami, FL, 1990. Illustrator Frank Angulo.) method.93 Swing and stance hydraulic
knees with yield rate control as
well as some microprocessor-
controlled knees can be adjusted to
lower the amputee from step to step
at a controlled rate. However, any
step-over-step method requires some

practice and confidence to perform so that the sound foot may advance to
safely. the step above. As the sound side hip
extends, the prosthetic side hip must
Step-By-Step flex at an accelerated speed to achieve
This method is essentially the same sufficient knee flex:ion to place the
for amputees at all levels of lower prosthetic foot on the next step
limb amputation. When ascending above.93
stairs, the body weight is shifted to Descending stairs is achieved by
the prosthetic limb as the foot of the placing only the heel of ilie prosthetic
sound limb is firmly placed on the foot on the stair below, then shifting
stair tread. The trunk is slightly flexed the body weight over the prosthetic
over the sound limb as the knee ex- limb, thus passively flexing the knee.
tends, raising the body and the pros- The sound limb must quickly reach
thetic limb to the same step. The pro- the step below in time to support the
cess is repeated for each step. When body weight. The process is repeated
descending stairs, the weight is shifted at a rapid rate until a rhythm is
to the sound limb as the prosthetic achieved. Most transfemoral ampu-
limb is lowered to the step below by tees who have mastered this skill with
eccentrically flexing the knee of the mechanical knees descend stairs at an
sound limb. Once the prosthetic limb extremely fast pace, much faster tl1an
is securely in place, the body weight is would be considered safe for the aver-
transferred to the prosthetic limb, and age amputee. With mechanical knees,
the sound limb is lowered to the sam'e both ascending and descending stairs
step. step-over-step is so difficult and
One of the primary goals for as- Figure 22 Transfemoral stair ascent by
energy-demanding for transfemoral skipping a step fo r the purpose of in-
cending stairs step-over-step is to in-
amputees that many who master these creasing speed. (Copyright © Advanced
crease the speed of ascent, but this Rehabilitation Therapy, Inc, Miami, FL,
skills prefer the step-by-step method.
comes at the cost of increased effort 1990. Illustrator Frank Angulo.)
As noted earlier, the use of swing and
and decreased safety. A variation on
stance hydraulic knees and the recent
the step-by-step method that counters
availability of microprocessor-con- Curbs
these objections is to simply skip a
trolled knees appear to have made
stair with tl1e sound limb and raise The same methods described for as-
step-over-step mobility easier and less
the body by placing the prosthetic cending and descending stairs are
limb on the same step (Figme 22). stressful for a broader range of ampu-
tees.93 used for curbs. Depending on the
This technique, however, is usually re- level of skill, the amputee can step up
served for ilie most physically fit am- or down curbs with either leg.
Transtibial Amputees
putees.
Step-Over-Step Stair Activity
Uneven Surfaces
Transfemoral Amputees When ascending stairs, the transtibial
amputee who cannot dorsiflex the Good gait training practice requires
Step-Over-Step Stair Activity
foot and ankle assembly must gener- that the amputee ambulate over a va-
Timing and coordination are critical
ate a stronger concentric contraction riety of surfaces such as concrete,
in step-over-step stair climbing. As
of the knee and hip extensors to suc- grass, gravel, uneven terrain, and vari-
the transfemoral amputee approaches
cessfully transfer body weight over able carpet thicknesses. Initially, the
the stairs, the prosthetic limb is the
the prosthetic limb. Descending stairs new amputee will have difficulty rec-
first to ascend the stairs by rapid ac-
celeration of hip flexion with slight is very similar to normal descent ex- ognizing the different surfaces sec-
abduction to achieve sufficient knee cept that only the prosthetic foot heel ondary to the loss of proprioception.
tlexion to clear the step. Some trans- is placed on the step. This compen- To promote increased visual aware-
femoral amputees will actually hit tl1e sates for the lack of dorsiflexion ness of these differences, the amputee
approaching step riser with the toe of within the foot and ankle assembly. 93 should spend time practicing on vari-
the prosthetic foot to achieve ade- ous surfaces. In addition, the amputee
quate knee flex:ion. With the pros- Crutches must realize that in many circum-
thetic foot firmly on the step, usually When climbing stairs with crutches, stances, it is important to observe the
with the toe against the riser of the both crutches may be held in the terrain ahead to avoid hazards such as
next step, the residual limb must exert hand opposite the handrail or can be slippery surfaces or holes that might
enough force to fully extend the hip used in the traditional manner. ca use a fall. 93

Ramps and Hills remains slightly posterior to act as a with possible buckling of the knee.
Ascending inclines presents a prob- firm base by keeping the weight line The most comfortable method of
lem for lower limb amputees because anterior to the knee. During descent backward walking for transfemoral
of a hill, the prosthetic limb leads but amputees is to vault upward (plantar
of the lack of dorsiflexion in most
remains slightly posterior to the flex) on the sound foot to obtain suf-
prosthetic foot and ankle assemblies.
sound limb. The prosthetic knee re- ficient height for the prosthetic limb
For most lower limb amputees, de-
mains in extension, again acting as a to clear the ground as it moves poste-
scending inclines is even more diffi-
fo rm of support so that the sound riorly. In this maneuver, the pros-
cult than ascending, primarily be-
limb may lower the body. For thetic foot is placed well behind the
cause of the lack of plantar flexion in
transpelvic amputees or patients who sound limb with most of the body
the foot and ankle assembly. Trans-
have had a hip disai-ticulation, side- weight being borne on the prosthetic
tibial amputees and amputees with
stepping is the most common alterna- toe, which keeps the weight line ante-
prosthetic knees have the added di-
tive regardless of the grade of the in- rior to the knee. The sound limb is
lemma of the weight line falling pos-
cline. Ultimately, the most accepted then moved back, usually at a slightly
terior to the knee joint, which results
method for use over a variety of in- greater speed for a somewhat shorter
in a flexio n moment. Advanced knee distance. The trunk is also maintained
clines and conditions such as wet sur-
uni ts with microprocessor-controlled faces and ice, regardless of amputa- in some flexion to maintain the
stance phase automatically compen- tion level, is the use of another weight forward on the prosthetic toe.
sate by increasing knee stability, so With a little practice, most amputees
person's shoulder. For example, while
descent is much easier to master. descending an incline, the amputee become quite proficient in walking
When ascending an incline, the body will walk one step behind an assistant backwru·d.
weight shoul d be slightly more for- with a hand on the assistant's shoul-
ward than normal to obtain maxi- der. As the two walk down the incline, Multidirectional Turns
mum dorsiflexion with articulating the speed of decent is controllable, Changing direction during walking or
foot and ankle assemblies or to keep giving the amputee more confi- maneuvering within confined areas
the knee in extension. Depending on dence.93 often increases an amputee's diffi-
the grade of the incline, pelvic rota- culty in controlling the prosthesis. Sit-
tion with additional acceleration may Sidestepping uations such as crowded restaurants,
be required to achieve maximum Sidestepping, or walking sideways, elevators, o r simply t urning around
knee flexion during swing. Descend- can be introduced to the amputee at are often overcome by "hip hiking"
ing an incline usually occurs at a various times thrnughout the rehabil- the prosthesis and pivoting aroUJ1d
more rapid pace than normal because itation program. The patient can be- tie sound limb. This method is effec-
of the lack of plantar flexion, result- gin with simple shifting of weight in tive but hardly the most aesthetic
ing in decreased stance time on the the parallel bars. With practice, more means of changing direction. When
prosthetic limb. Amputees with pros- complex activities can be performed turning to the sound side, two key
thetic knees must exert a greater than such as unassisted sidestepping factors for a smooth transition in-
normal force on the posterior wall of around tables or completing a small clude maintaining pelvic rotation in
the socket to maintain knee exten- obstacle course that requires many t he transverse plane and performing
sion unless they have a knee with small turns. During early rehabilita- the turn in two steps. The prosthetic
a microprocessor-controlled stance tion, sidestepping provides the ampu- limb is crossed 45° over the sound
phase, which automatically increases tee with a functional exercise for limb, the sound limb is rotated 180°,
knee stiffness, reducing the effort to strengthening the hip abductors; later and the turn is completed by stepping
control the knee; however, pelvic con- in the rehabilitation process, it pro- in the desired direction with the pros-
trol is still required. Most lower limb vides an opportunity to progress to thetic limb, leading with the pelvis to
amputees find it easier to ascend and multidirectional movements. 93 ensure adequate knee fleXIon. 93 (F.1g-
descend inclines with sh ort, but ure 23).
equal, strides. This method is often Wa lking Backward Turning to the prosthetic side is
preferred because it simulates a m o re Walking backward is not difficul t for performed in almost the same way ex-
normal appearance as opposed to a transtibial amputees but poses a cept that slightly more body weight is
sidestepping or zigzag method. 93 problem for those with a prosthetic maintained o n the prosthetic toe to
When ascen.ding and descending knee because there is no means of ac- keep the weight line anterior to the
hills, the amputee will find sidestep- tively flexing the prosthetic knee for knee, thus preventing knee flexion.
ping to be the most efficient means. adequate ground clearance. In addi- The sow1d limb is crossed 45° over
The sound limb should lead, provid- tion, the posterior forces tend to the prosthetic limb, automatically
ing the power to lift the body to the cause the weight line to fall posterior throwing the weight line forward. The
next level, while the prosthetic limb to the k nee, causing a flexion moment prosthetic limb is rotated as close to

180° as possible without losing bal-

ance (135° is usually comfortable),
and the turn is completed by stepping
4 4
in the desired direction with the
sound limb (Figure 24). If necessary,
remind the transfemoral amputee to
maintain knee extension by applying
a force with the residual limb against
3
the posterior wall of the socket.
One exercise that will reinforce
turning skills is follow the leader, in
which the amputee follows the physi-
cal therapist in making a series of
turns in all directions with varying
speed and degrees of difficulty. 2 2 s 6
The level of skill in turning varies
among amputees. All functional am-
bulators should be taught to turn in
~ 5
both directions regardless of the pros-
thetic side. Lower limb amputees with
poor balance, however, may be lin1-
I{ I
ited to unidirectional turns, requiring 1 1
a series of small steps to complete tht!
turn. 6 }j
Tandem Walking
Walking with a normal BOS is of (!)
prime importance; however, tandem
walking can assist with balance and
coordination, as well as improve
awareness of the prosthesis. After Figure 23 To turn to t he sound side, the Figure 24 To turn to the prosthetic side,
placing a 2- to 4- in wide strip of tape amputee completes the fol lowing se- the amputee completes the following se-
on the floor, the amputee is asked to quence. 1 to 3, Maintain normal gait bio- quence. 1 to 3, Maintain normal gait bio-
walk in three ways. The amputee first mechanics. 4, Move t he prosthetic limb mechanics. 4, Move the sound limb over
over the sound limb 45°. 5, Rotate t he the prosthetic limb 45°. 5, Rotate the
walks with one foot to either side of prosthetic limb approximately 135°.
sound limb 180°. 6, Complete t he turn by
the line, then along the line, heel to stepping in the desired direction. (Copy- 6 and 7, Complete the turn by stepping in
toe, with one foot in front of the right © Advanced Rehabilitation Therapy, t he desired d irection. (Copyright © Ad-
other. Finally, the amputee walks with Inc, Miami, FL, 1990. Illustrator Frank An- vanced Rehabilitation Therapy, Inc, Mi-
one foot crossing over in front of the gulo.) ami, FL, 1990. Illustrator Frank Angulo.)
other so that neither foot touches the
line, with the left foot always on the sist with balance and likewise, trunk are recommended in the event that
right side and vice versa. 93 rotation will increase, further empha- balance is lost. 93
Braiding sizing the need for independent
movement between the trunk and Falling
Braiding (cariocas or grapevine step)
pelvis.93 Controlled falling and lowering to the
may be taught either in the parallel
floor are important skills not only for
bars or in an open area, depending on Single-Limb Squatting safety but also as a means to perform
the amputee's ability (Figure 25).
Single-limb balance is taught during activities on the floor. During falling,
Simple braiding consists of crossing
one leg in front of the other. As the the early stages of rehabilitation for amputees must first discard any assis-
amputee's skill improves, the leg can crutch walking, hopping, and other tive device to avoid injury and ensure
alternate, first in front of and then be- skills. Single-limb squatting is consid- they land on their hands with the el-
hind the other leg. As ability im- erably more difficult but can help im- bows slightly flexed to reduce the
proves, the speed of movement prove balance and strength. When force and decrease the possibility of
should increase. With improved first attempting this skill, half squats injury. As the elbows flex, the ampu-
speed, the arms will be required to as- with a chair underneath the patient tee should roll to one side to fmther

in the elderly. J Clin Epidemiol 1992;43:

791-798.
7. Deathe B, Miller WC, Speechley M:
The status of outcome measurement
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8. Day HJB: The assessment and descrip-
tion of amputee activity. Prosthet
Ort/wt Int 1981;5:23-28. I!
9. Hubbard W, McElroy G: Benchmark
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Orthotlnt 1994;18:142- 149.
10. Wood-Dauphinee S, Opzoomer A,
Figure 25 Braiding is an exercise designed to improve prosthetic control, balance, and Williams J, Marchand B, Spitzer W: 21
coordination by crossing o ne leg in front of or behind the other leg in a continuo us Assessment of global function: The
manner. (Copyright© Advanced Rehabilitation Therapy, Inc, Miami, Fl, 7990. Illustrator reintegration to normal living index.
Frank Angulo.) Arch Phys Med Rehabil 1988;69: 2
583-590.
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trolled mauner is initiated by squat- putees will use their prostheses and Framework of a Prosthetic Follow-up 2
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gently leaning forward onto the of activity. The primary goal of the lkole de Readatation, Farnlte de Med-
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Prosthet Orthot Int 1997;21:183-186. pelvic list on the vertical displacement

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Bilateral Lower Limb Prostheses
Introduction
As medical care and rehabilitation Patient Evaluation ses. Tbe authors conclude that most
techniques continue to improve, peo- atherosclerotic bilateral transtibial
Prior Experience Using a
ple are living longer, resulting in an amputees can use prostheses and that
Prosthesis the high survival rate and low rate of
increase in the number of patients
with conditions that require bilaten!l Many dysvascular amputees will have residual limb revisions justify restor-
amputations. The bilateral lower limb had experience as a unilateral ampu- ative efforts. Evans and associates 1
amputee presents unique challenges tee before the second amputation. concluded that a high survival rate
to the rehabilitation team. Most bilat- Prior experience using a unilateral (60% at 2 years and 40% at 5 years) as
eral amputations are performed be- prosthesis is a good indicator of fu- well as the fact that a significant num-
cause of vascular disease with or ture success with bilateral prostheses. ber of patients become independent
without diabetes. The Centers fo r In the absence of other concurrent and ambulatory justify an aggressive
Disease Control and Prevention re- disabilities, the patient with a second approach to the rehabilitation of the
ports that between 1980 and 1996, t he transtibial amputation could achieve bilateral amputee. The demonstrated
number of patients discharged from a level of independence similar to that period of survival offers ample op-
hospitals who had undergone diabe- attained following the first amputa- portunity for rehabilitation profes-
tes-related lower limb amputations tion.2 Evans and associates 1 report sionals to improve the quality of these
increased from 36,000 to 86,000 per that in their series of bilateral trans- patients' remaining years. The life ex-
year. In addition, peripheral vascular tibial amputees, where no selection pectancy of these patients is limited,
disease accounts fo r more than 30,000 criteria was used, 23 of 46 patients however, so rehabilitation that aims
lower limb amputations each year. 1 (50%) who were ambulators before to reintegrate these patients into theil"
In a review of 489 patients with contralateral amputation became bi- places in society and to avoid unnec-
end-stage peripheral vascular disease lateral prosthesis users. This is in con- essarily lengthy periods away from
who required major amputation of a trast to only 4 of 59 patients (6.8%) their homes should be expedited.3
lower limb, Evans and associates 1 re- who were not ambulators before con-
ported that 24% required amputation tralateral amputation. The authors Traumatic Injury
of the contralateral limb and that in conclude that "successful prosthetic Bilateral lower limb amputations re-
56% of the patients the second am- rehabilitation in the bilateral amputee sulting from traumatic injury are
putation was performed less than appears primarily dependent on the rare. Often the individuals who sus-
1 year after the first. Esquenazi2 re- use of a prosthesis before contralat- tain traumatic injury resulting in bi-
ports that 50% of patients who un- eral amputation and/or the preserva- lateral loss are young and in other-
dergo a lower limb amputation be- tion of at least one knee joint." wise good heal th, so the rehabilitation
cause of disease are at risk for potential is excellent.
amputation of the contralateral limb Atherosclerosis
within 3 years. In light of these sta- ln a retrospective assessment of 80 bi- Knee Salvage
tistics, it is dear that health care pro- lateral transtibial amputees, Thornhill The importance of saving the knee
fessionals serving the needs of ampu- and associates3 found that 71 o/o of whenever possible cannot be overem-
tees should be well versed in the the atherosclerotic patients achieved phasized. When a unilateral lower
special needs of the bilateral amputee. some function with bilateral prosthe- limb amputee loses the second limb,

the chance of the patient achieving and associates 7 are (1) pelvic rotation , mal. The authors concluded that the
functional use of the prostheses is (2) pelvic list (dip), (3) knee flexion knee joint is a major determinant of
measurably higher if one or prefera- in stance phase, (4) plantar flexion/ the energy cost of ambulation and of
bly both knee joints have been pre- knee flexion (early stance), (5) foot/ successful rehabilitation of the older
served. Most unilateral transtibial knee interaction (late stance), and amputee.
amputees who ambulated successfully ( 6) lateral displacement of the pelvis. H uang and associates 15 reported
with a prosthesis can also master bi- Acting in concert with these six de- on four bilateral transfemoral ampu-
lateral amputee gait if the amputation terminants of gait is synchronous tees (mean age, 34 years) and found
performed on the contralateral limb transverse rotation of the segments of they expended 300% mo re energy per
is transtibial or more distal.4 The suc- the lower limb. 6 Through these six , unit distance than did the able-bod-
cess of rehabilitation decreases dra- motion patterns, vertical and hori- ied subjects. In a study of five other-
matically with transfemoraJ or higher zontal displacements of the center of wise healthy bilateral transfemoral
level amputations. mass are believed to be minimized, amputees {mean age, 22 years), Hoff-
thereby reducing the muscular effor t m an and associates 16 found that the
General Health of walking and consequently saving metabolic cost at the chosen walk-
Ambulation should be attempted only energy. To addition, abrupt changes in ing speed for the amputees was
if the patient demonstrates adequate direction of the center of mass are 0.32 mL/kg/m. This was 88% higher
cardiac function, strength, balance, avoided, which also saves energy.8 than the value of 0.17 mL/kg/m for
and endurance. 2 Coronary artery dis- During the initial contact and the able-bodied subjects. In light of
ease in an elderly, dysvascular trans- loading response phases of gait, shock the tremendous energy expenditures
femoral or bilateral amputee indicates absorption is a primary function of necessary to walk using bilateral
a poor prognosis for am bulation with normal walking. 8 Controlled move- transfemoral prostheses, Esquenazi2
prostheses.5 ments of the knee, ankle, an d subtalar states that "Most transfemoral bilat-
joints along with pelvic list dampen eral amputees over 50 years of age
Flexion Contractures th ese forces. 6•8 - 11 The amputee's com- will find the wheelchair an easier and
Flexion contractures at the hip and/or fort will be enhanced to the degree
more practical means of locomotion."
knee can seriously limit the patient's this shock absorption is successfully
Certainly if the bilateral transfemoral
ability to ambulate with prostheses. replaced by the prosthetic compo-
amputee is to ambulate successfully,
Early attention to the prevention of nents. This is especially true for the
all possible means available should
such contractures is critical to the bilateral amputee, in whom the loss of
be used to reduce the energy expen-
successful use of prostheses by the bi- physiologic shock absorption cannot
d iture.
lateral amputee. be compensated for by the contralat-
• To improve the chances for func-
eral limb.
tional ambulation, it is of paramount
Normal Human Energy Consumption importance that the knee joints be
preserved. Retention of maximum
Locomotion and the Energy consumption studies in bilat-
limb length by amputation at the
eral amputees are limited. The avail-
Determinant s of Gait able data suggest that walking with
most distal level suitable is particu-
The more joints and muscles that are larly important for the bilateral am-
two prostheses of a particular level
lost to amputation, the greater the putee, to provide maximum bony le-
requires more energy than does walk-
loss of the normal locomotor mecha- ing with one prosthesis of that same verage to control the prosthesis.4
nisms and therefore the greater the level and that energy consumption
energy cost of ambulation and the de- increases as the amputation level be- Lowering the Center
gree of disability.2 Loss of normal comes more proximal. 12 DuBow and
physiologic function at the various associates 13 studied six bilateral dys-
of Gravity
amputation levels leads to increased vascular transtibial amputees walking Tra nstibial Amputees
energy consumption, loss of shock at a natural pace and found that they For t he bilateral amputee, lowering
absorptio n, and abnormal gait pat- required 123% more Vo2 (mL/kg/m) the center of gravity is believed to
terns. With higher amputation levels, and had a 26% higher heart rate and provide better balance and control of
the effects of these losses become 36% slower velocity than a normal the prostheses. The optimal shin
m ore pronoun~ed. To evaluate these group during ambulation. Gonzalez length for most bilateral transtibial
functional deficits, it is useful to study and associates 14 found the energy ex- prostheses is that which allows easy
the elements of normal human walk- penditure of walking in bilateral standing from a chair of typical
ing. The elements of walking, or de- transtibial amputees and unilateral height. In most cases, the prosthetic
terminants of gait, as described by In- transfemoral amputees was, respec- feet should be in full contact with the
ma n and associates6 and Saunders tively, 41 % and 65% higher than nor- floor while the amputee is seated

Chapter 49: Bilateral Lower Limb Prostheses 623
Figure 1 Prostheses w ith a medial tibial

plateau height of approximately 18 in-
ches faci litate getting out of a chair and
allow the feet to rest on the floor when
the amputee is seated.
(Figure 1). A shin length that provides

a medial tibial plateau height of 18 in-
Figure 3 Length can be added to the en-
ches with the shoe on is therefore i' Figure 2 Stubbies with rearward-facing
doskeletal stubby prostheses as the am-
good starting length for the shin. For SACH feet are used during initial gait
putee gains confidence, strength, and
training.
individuals of short stature, these val- balance.
ues do not apply, and it is usually
preferable to match the patient's pre- the erect position without fea r of fall-
operative shin length. ing. This feeling of security is even
more important for adult amputees as
Transfemoral Amputees they learn to balance on prostheses
and "Stubbies" (Figure 3) because adults are more
likely to be injured when they fall and
For the bilateral transfemoral ampu-
therefore their fear of falling is greater.
tee, the benefits of a lower center of
For most bilateral transfemoral
gravity can be achieved through the
amputees, stubbies are recommended
use of "stubbies" (Figure 2), which of-
as a transitional phase of rehabilita-
fer potential advantages over conven-
tion, in which case conventional pros-
tional prosthetic devices in terms of thetic feet turned rearward can be
safety, stability, and energy efficien- Figure 4 A tilt t able, which allows con-
used in place of custom-made rock- trolled and graded weight bearing, is
cy.17 Stubbies are short prostheses that
ers. Stubbies provide amputees with a helpful when treating more debilitated
use rocker-bottom platforms attached means to become upright and to be- amputees.
directly to the end of the socket or come confident in their ability to am-
close to it. The arc of the rocker is de- bulate in a relatively safe and stable consideration the height of a standard
termined by using the hip as the cen- manner. chair. The ischial height should be no
ter point. The rocker extends posteri- Training in the use of stubbies less than 18 inches with shoes on; this
orly to prevent the amputee from should begin on a tilt table. Initially, minimizes the amount of lifting the
falling backward. This alJows the user the amputee may be brought to an amputee must accomplish to position
to sit back in the prostheses with the upright weight-bearing position on the body in a chair. Obviously, upper
hips flexed, thereby maintaining a the tilt table (Figure 4) . In this way, limb conditioning is an important
normaJ amount of lumbar lordosis. In socket fit and comfort can be as- consideration for the bilateral lower
discussing the use of stubbies for the sessed, and graded weight bearing can limb amputee, especially when the
infant or child with bilateral lower be controlled. Once the amputee is amputations are at the transfemoral
limb deficiencies, Kruger 18 states that comfortable in a fully upright posi- level.
the lower center of gravity prov-ides a tion on the tilt table, training can As the amputee gains confidence in
greater sense of stability, making it proceed using parallel bars and then a using stubbies, length can be added
much easier fo r the child who is be- walker or canes (Figure 5) . Again, the progressively to the endoskeletal pros-
ginning to "cruise" to begin to walk in minimum height should take into theses. The rate of progression to full -

Figure 5 A, Initial gait training can be performed using a short walker for stabilit y.
B, The amputee can progress t o the use of two canes as confidence is gained. ·
Figure 6 After t he amputee is successful

with stubbies, f ull-length prostheses can
be provided. In this patient, one locked
knee and one fou r-bar knee are used for
stability.
tailed discussion of component selec-

tion is presented later in this chapter.
For some amputees, long-term use
of stubbies is appropriate. If the am-
J:'utee finds that full-length legs are
unmanageable or create too much
anxiety because of the possibility of
falling, then definitive use of stubbies
is indicated. Additionally, some ampu-
tees who use full -length prostheses
choose to have a set of stubbies that
are used primarily in the home or for
Figure 7 The fu nctional length limit of outdoor recreational activities. These
stubbies is reached w hen negotiating are usually patients who regard nor-
tight spaces in t he wheelchair becomes mal height to be important for psy-
impossible. Figure 8 Definitive use of st ubbies is
chosocial reasons when interacting
sometim es desirable. This t ri lateral ampu-
tee enjoyed t he security, stability, and with the public, yet at home they may
length articulated limbs is determined reduced energy requirement of short enjoy the ease of use of the shorter
by the success and confidence of the prostheses. Note the posterior foot place- limbs. The feet used on definitive
user (Figure 6) . When the overall ment, which is required when using stubbies can be either rockers,
length has been increased to the point forward-facing feet.
rearward-facing prosthetic feet, or
that the foot can be placed sufficiently forward-facing prosthetic feet that
posterior to prevent the amputee from seated in a wheelchair (Figure 7). have been positioned sufficiently pos-
falling backward, the feet should be Locking knees may be used initially terior to provide stability (Figure 8).
turned to the normal, forward -facing and unlocked to drop the feet out of The height of the definitive stubbies
position. Knees should be included the way while sitting, but progression should take into account not only
when the limbs become too long for to at least one free knee with sufficient chair height but also the height of
the amputee to easily negotiate door- inherent stability on the longer or work surfaces and counters in the
ways and restricted spaces while dominant side is desirable. A more de- home.

Excessi\Le lordosis Reduced lordosis Minimal lordosis
COM
COM
5° socket 15° socket \ \ \ 15° socket

flexion ~ flexion \:0 flexion
A
t
Center of pressure B
L t
Center of pressure c
Plantar flexed
t
alignment
Center of pressure
•
Figure 9 Excessive lumbar lordosis may result from improperly aligned prostheses. In the presence of an unaccommodated f lexion con-
tracture, the amputee must extend at the lumbar spine to position t he center of body mass (COM) over the base of support. A, With
socket flexion of 5° from vertical, excessive lordosis is required to position the COM over t he center of pressure. B, Socket flexion of 15°
lessens the amount of lumber lordosis required to maintain a stable posture. C, Dynamic response f eet aligned in plantar flexion cause
the amputee to lean forwa rd over t he flexible toe lever, further f lattening t he lumbar spine.
Crouse and associates 19 compared transferring and in climbing stairs, The new dynamic response feet
oxygen consumption and cardiac re- curbs, and ramps. 20 make it possible to align the pros-
sponse in a bilateral transfemoral thetic feet in plantar flexion, reducing
amputee using stubbies and fuU- lumbar lordosis (Figure 9, C) . Plantar
Minimizing Lumbar flexed alignment with these feet,
length prostheses and found the
stubbies to be 24% more efficient. Lordosis which provide an elastic or spring-
They also recorded an interesting ir- like dorsiflexion action, causes the
Bilateral transfemoral amputees com-
amputee to lean forward over the feet
regularity in expiratory flow wave- monly adjust their posture to position
to find a point of stability. This shift
forms found to be related to the stride the center of body mass over the base of the center of pressure to a relatively
frequency during use of the stubbies. of support, increasing lumbar lordo- anterior position and the accompa-
This evidence indicates that when a sis. This abnormal posture is some- nying fo rward lean as the amputee
subject wears prostheses, reactive times associated with low back pain. brings the center of body mass over
forces associated with foot strike that The amount of lordosis increases with that point will lessen the lordosis (Fig-
are normally dissipated or stored as increased hip flexor tightness (Figure ure 9, C) . As Radcliffe 21 noted, this
potential energy in elastic tissues are 9, A). To avoid th is, it is important to plantar flexed alignment helps knee
instead transmitted to the torso, af- align the socket with sufficient initial stability during early stance phase and
fecting intrathoracic pressure and al- flexion , which is best determined by affords improved knee control during
tering pulmonary ventilation pat- measuring the flexion contracture us- late stance phase, allowing easier ini-
terns. The authors suggest that future ing the Thomas test and then adding tiation of knee flexion . To achieve an
prosthetic designs should include an additional 5° of flexion. Socket appropriate amount of plantar flex-
features that dissipate forces experi- flexion alone may not be sufficient to ion, a 6- to 10-mm space should be
enced dw-ing foot strike. reduce lumbar lordosis to normal val- created under the heel, with the shoe
The primary disadvantage of stub- ues (Figure 9, B). Also, with a long re- on, dur ing bench alignment (Figure
bies is cosmetic, which makes them sidual limb, cosmetic considerations 10). The amount of plantar flexion
unacceptable to many inclividuals. may limit the amount of socket flex- should be fine-tuned during dynamic
Other problems include difficulty in ion that can be achieved. alignment.

Figure 11 Bilateral transtibial amputee

Figure 10 Prostheses with plantar f lexed alignment. A, Prostheses aligned using a
shown using exoskeletal prostheses with
10-mm spacer during bench alignment to achieve the desired plantar flexed alignment
SACH feet. The vertical line has been
(shown without the spacers). B, Amputee standing in the prostheses with plantar f lexed
added for reference. A, Note the forward
alignment. Note the slight forward lean and the resulting f lattened lumbar spine. The
lean req uired for balance because of the
patient is well balanced and standing unsupported.
insufficient posterior lever arm, caused in
~ is case by heel cushions that were too
soft. B, Same patient using appropriately
Component The goal of providing shock absorp- aligned prostheses w ith multiaxial dy-
namic response feet, vertical shock units,
tion through compliance will be
Selection compromised if the foot is too stiff.
and vacuum-assisted suspension systems.
Feet/Ankles Appropriate prosthetic alignment of
Foot and ankle components that pro- properly selected components is criti- energy-efficient gait but they also im-
vide good shock absorption are gener- cal in achieving an optimal outcome prove speed control, especially during
ally indicated for bilateral amputees. (Figure 11) . For the transfemoral am- slow walking.
As previously discussed, shock absorp- putee, the plantar flex.ion action of the
tion is one of the primary functions of foot must be soft enough to allow Knee Components
the physiologic foot and ankle com- rapid transition to foot flat to enhance Radcliffe 2 1 documented the benefits
plex, and replacement of this feature is knee stability. Additionally, with the of aligning the prosthetic knee to
critical to the comfort and normal and transfemoral prosthesis, it is necessary achieve voluntary control including
efficient ambulation of the amputee. to select a foot with a spring-like dor- (1) knee stability at heel strike
Modern foot and ankle components siflexion action for the recommended through active control using the hip
that offer compliance and some mea- plantar flexed alignment to be success- extensors, (2) ease of initiating knee
sure of dynamic response should be ful. Dorsiflexion action that is too soft flexion in late stance during double
considered for all bilateral leg ampu- wiU fail to provide the necessary toe le- support, and (3) provision of a more
tees, regardless .of the level of amputa- ver needed both for anterior support natural gait that is energy efficient.
tion. Because of the high energy cost during standing as well as adequate For the active ( unlimited community
of walking with two prostheses, it is knee control after midstance. In my ambulatory) bilateral transfemoral
advantageous to use dynamic response experience, amputees who have used amputee, use of voluntary control
feet. A more flexible foot is generally high-energy-storing feet report that principles of alignment has proved
preferred over one that is more rigid. not only do these feet provide a more advantageous.

Hydraulic swing and stance knee the bilateral amputee. Some linkage
control units have been very success- configurations place the instant cen-
ful in optimizing the gait of the active ter of rotation in a posterior and
transfemoral amputee. These units proximal location, providing excellent
offer good stance stability, can be stability. In some cases, and particu-
locked for special circumstances, and larly for the active walker, the instant
are best aligned with the knee center center of rotation can be fine-tuned I
I I
in a relatively anterior position (com- by the prosthetist to balance the need
pared with less inherently stable defor stability at heel strike with the
'~
signs), which provides greater toe ease of knee flexion in late stance
clearance than does a more posteri- phase by adjusting the extension stop Posterior".d::
orly offset knee center (Figme 12). and thereby changing the position of
Less active transfemoral amputees the instant center of rotation within
who require a high degree of stability the zone of stability (Figure 13). Figure 12 The effect of shifting the knee
will benefit from knee mechanisms Four-bar knee mechanisms also offer in the sagittal plane is shown. Anterior
placement of the knee reduces the hip-
that are inherently more stable, in- the advantage of greater toe clearance
to-toe distance during swing phase. The
cluding use of a locking knee on one during swing phase (Figme 14) com- applicability of this approach depends on
side. In cases where one locking knee pared with single-axis hinges. This the inherent stability of the knee mecha-
is found to be necessary, the locking can be especially advantageous for bi- nism used. (Courtesy of Steven A. Gard,
lateral amputees. Ph.D.)
knee should be fitted on the shorter
or weaker side. In patients with one
transtibial and one transfemoral ama- Stance-Phase Knee Flexion
putation, it may be useful to shorten Lack of stance-phase knee flexion is energy. Several prosthetic knee mech-
the transfemoral side up to 12 mm for very noticeable in the gait of bilateral anisms that provide stance flexion
added swing-phase toe clearance. transfemoral amputees. Trus absence using a compliant linkage are now
of one of the key determinants of gait available. Knee mechanisms that al-
Polycentric knees results in an unnatural gait that lacks low stance-phase knee flexion should
Polycentric knee designs offer several the normal shock-absorbing mecha- not interfere with m1tiat1on of
interesting features that may benefit nism and i~ believed to require greater swing-phase knee flexion . Therefore,
Hip Joint force
Hip flexion moment +

Equivalent
single force
Load line
at push off
posterior to
instant center
A B
Heel contact Sl)per1mposed Push·Off
Figure 13 A. Four-bar knees w ith an adjustable extension stop allow the prosthetist to fine-tune the stability of the knee by selectively
positioning the instant center of rotation along the arc shown. (Reproduced with permission from Gard SA, Childress OS, Uellendahl
JE: The influence of four-bar linkage knees on prosthetic swing. J Prosthet Orthot 1996;8:34-40.) B) The zone of stability is described by
superimposing the stability requirements during heel strike with those required at heel-off, which allow optimal voluntary knee con-
trol. (Reproduced with permission from Radcliffe CW: The Knud Jansen lecture: Above-knee prosthetics. Prosthet Orthot Int 1977;1:
146-160.) .

hi{
Q\ Hip center tra
Knee In
\ alignment So
\ point tee
fo1
Apparent pr,
shank shortening sh
• • SU
bo
(3
an
m
or
wi
Figure 14 The effect of a particular four-
bar knee on the trajectory of the foot is
sp
characterized by knee f lexion, apparent p<
ankle dorsiflexion, and apparent shank tr
shortening. (Reproduced with permission fu
from Gard SA, Childress DS, Uellendahl 31
1£: The influence of four-bar linkage
C(
knees on prosthetic swing. J Prosthet
Orthot 1996;8:34-40.) m
Figure 15 Vertical shock units afford Figure 16 Vertical shock units replace w
greater comfort for t he bilateral ampu- some of the normal physiologic compli- ta
knees that rely on weight-activated tee. In this case, torque absorbers are in- ance lost by amputation. With such units,
corporated into the same unit and are it can be beneficial to use four-bar knees
si
braking should be avoided because used in combination with low-profile dy- that offer sufficient swing-phase shorten- fc
they will hamper the ability of the namic response feet to maintain an ac- ing to make up fo r the reduced height tl
amputee to initiate flex.ion late in ceptable overall length. during midstance on the weight-bearing b
stance during the preswing phase of side. b
double support. controlled knee also offers an optional
flexion lock, which is useful for the bi- ~rated into the transfemoral pros- 0
Microprocessor-Control led ti
lateral amputee. thesis, it may be beneficial to use a
Swing and Stance four-bar knee (Figure 16) to gain the c
Perhaps one of the most important Vertical Shock Units additional toe clearance such knees LI
developments in prosthetic compo- Vertical shock units offer another op- offer.22
nents in recent years was the introduction for reduction of the impact F
tion of microprocessor-controlled forces experienced during normal gait Torque Absorbers c
knee units. One such computerized as well as the peak forces that result When the foot is on the floor during
knee uses real-time analysis of various from stepping down from a height the stance phase of gait, the biologic
parameters of gait to provide a high (Figure 15). Vertical shock units in- foot and ankle permit the leg to rotate
degree of stability during the loarung crease compliance in the prosthesis, externally while the foot remains sta-
response phase of gait and nearly allowing body weight to be trans- tionary. 6 These capabilities are lost
eliminate resistance to flex.ion late in ferred to the prosthetic limb over a following amputation. Therefore, us·
stance, lowering the energy require- longer period of time, thereby de- ing a torque absorber to minimize the
ments for walking. Because of the high creasing the downward acceleration rotational shear fo rces that would
resistance to flexion in early stance, of the body and consequently reduc- otherwise be experienced at the
the knee center can be placed in a rel- ing forces transmitted through the socket interface is beneficial. Clinical
atively anterior position, affording prosthesis to the body. 11 Because of observation and user feedback also
greater toe clearance. Such anterior the inherent shortening that occms suggest that torque absorbers allow
knee alignment-also encourages use of during stance phase with these units, greater step length because they facil-
the stance flexion feature, as the am- sufficient contralateral toe clearance itate external rotation between mid-
putee allows the knee to flex against during gait must be ensured by care- stance and terminal stance. This is
the high hydraulic resistance in re- fully adjusting the amount of com- particularly significant in the trans-
sponse to loading. At least one compression provided by the shock tmit. femoraJ amputee with a flexion con-
mercially available microprocessor- When vertical shock units are incor- tracture because such limitations in

hip range of motion restrict con- is recommended whenever possible,

tralateral step length. for all cases and levels of amputation.
For the transfemoral amputee who
Interlace Design may have difficulty donning a con-
Socket design for the bilateral ampu- ventional suction socket, silicone suc-
tee is not significantly different than tion suspension (3S) is a good alter-
for the unilateral amputee. Sound native. 23 The benefits of 3S socket
prosthetic interface design principles designs include (1) ease of donning
should be used, including (1) total while in a seated position, (2) mainte-
surface bearing, (2) close coupling of nance of suction throughout the
bony structures to the prosthesis, and range of motion, and (3) easy accom-
(3) excellent suspension. Transtibial modation of volume changes while
amputees benefit from soft interface maintaining suction. Belts can be
materials such as silicone, urethane, added to the transfemoral prosthesis
or thermoplastic gel liners that, along to enhance mediolateral stability. The
with appropriate socket design, belt should have a split design that al-
Figure 'il7 Because of t heir fl uid-like
spread forces evenly over the greatest lows the prosthetic legs to be sepa- characteristics, gel interfaces spread the
possible area (Figure 17). Bilateral rated from each other for prosthesis forces of walking more evenly. The gel
transfemoraJ amputees have success- maintenance and other circum- liners shown incorporate distal locking
fully used both ischial containment stances. mechanisms for secure suspension.
and quadrilateral sockets. lf ischial
containment designs are indkated,
more aggressive containment on the'
Other Considerations Case Studies
weaker or shorter side and less con- Bilateral prostheses for ambulation Case Study 1
tainment on the stronger or longer are not the only option for bilateral A 67-year-old man presented with bi-
side may be advisable because the dif- amputees with transfemoral or higher lateral transtibial amputations sec-
ferent medial brim heights will reduce limb loss. Nonprosthetic consider- ondary to peripheral vascular disease
the tendency for pinching of the skin ations include posteriorly offset with diabetes. The individual was oth-
between the two sockets during am- wheelchair wheels to prevent flipping erwise in good physical condition.
bulation. over backw;ard because of the higher Both limbs had been amputated 5 in-
To obtain an adequate impression center of gravity. Additionally, ampu- ches below the knee. The left limb was
of the limbs in the new bilateral tees who are not candidates for am- amputated 18 montl1s after the right,
transfemoral amputee, the amputee bulation may wish to be fitted with and the individual had successfully
can be positioned either supine or ly- "sitting" prostheses for cosmetic rea- used a unilateral prosthesis before the
ing on the side. At the time of the first sons. In some cases, a prosthesis may
second amputation. The left limb was
socket change, casting can be accom- be used solely for transfers. One ex-
managed with a rigid dressing imme-
plished with the amputee in the more ample would be the transtibial/
diately after the amputation. This was
conventional upright position by hav- transfemoral amputee for whom am-
followed by a removable rigid dress-
ing the amputee alternately stand in bulation is not feasible but for whom
ing used in combination with the pro-
first one and then the other initial the unilateral use of a tra11stibial
gressive addition of socks to encour-
prosthesis while supported between prosthesis improves independence
a11d function. Even in patients who age shrinkage, as described by Wu and
parallel bars.
are not candidates for a1nbulation, Krick. 25 The individual has followed a
Suspension a111putation through the knee is pref- strengthening and conditioning pro-
Suspension of a prosthesis is always erable to bilateral transfemoral ampu- gram as outlined by the rehabilitation
critical and assumes even more im- tation because the longer residual team's physical therapist. A prepara-
portance for the bilateral amputee. limb provides more secure balance tory prosthesis was provided 3 weeks
Any amount of pistoning in the while seated in a wheelchair. 24 Al- postoperatively, at which time the
socket will increase the effective though wheelchairs provide safe and limb was well healed and only slightly
length of the prosthesis dming swing efficient transportation, exclusive use bulbous. The socket was a total-sur-
phase, and the bilateral amputee can- of a wheelchair has many disadvan- face-bearing design that used a gel-
not actively vault to compensate. Pos- tages because of environmental barri- type roll-on liner with pin suspen-
itive suspension will also provide bet- ers such as stairs. Many bilateral lower sion, and a dynamic response foot
ter proprioception and will reduce limb amputees are best served by us- with built-in multiaxial rotation was
shear forces and the perception of ing prostheses in conjunction with a provided. These components matched
weight. Therefore, suction suspension wheelchair. those of the endoskeletaJ prosthesis

630 Section UI: The Lower Limb
the individual had been using. At the ion contractures, and upper lin1b mination of the amputee to succeed, a
time of initial fitting, the prostheses strengthening. After only 2 weeks of positive outcome is attainable. The re-
were adjusted to reduce the inclividu- training, the man was able to manage habilitation team should remain open
aJ's overall height 2 inches to provide prostheses that were 4 inches longer to new ideas. Thoughtful use of avail-
greater stability and confidence. Dur- and was able to don the sockets inde- able assistive technologies including
ing the fitting, it became clear that the pendently using a nylon pull sleeve. state-of-the-art prosthetic compo-
foot on the existing prosthesis would He was also able to independently get nents can significantly benefit the bi-
need to be more flexible because the into and o ut of his wheelchair, which lateral lower limb amputee.
activity level and the vigor of the has offset wheels for greater stability.
man's gait would be reduced by the The patient was eager to progress to
second amputation. Therefore, a new, articulated legs, so locking hydraulic References:
softer foot to match the new antici- knees with swing and stance control 1. Evans WE, Hayes JP, Vermilion BD:
pated activity level was provided. The were installed and the Solid Ankle Rehabilitation of the bilateral ampu-
man received gait training for the first Cushion Heel (SACH) feet were re- tee. J Vase Surg 1987;5:589-593.
I
3 weeks after receiving the initial placed with forward -faci11g dynamic 2. Esquenazi A: Geriatric amputee reha-
prosthesis and met his rehabilitation response feet of appropriate stiffness. bilitation. Clin Geriatr Med 1993;9:
goals. Five months after he received The flexion contractures were still 73 1-743.
the initial prosthesis, he was fitted present, so the alignment was set to 3. Thornhill HL, Jones GD, Brodzka W,
with a pair of new prostheses of the accommodate the contractures. With VanBockstaele P: Bilateral below-knee
same design and components as the the added length, the patient became amputations: Experience with 80 pa-
tients. Arch Phys Med Rehabil 1986;67:
initial prostheses with the addition of more tentative and cautious, prefer-
159-163.
bilateral vertical shock units. The man ring to stay within the parallel bars
4. Sm ith DG, Burgess EM, Zettl JH: Spe-
has reported that the vertical shock with the knees locked for the next few
cial considerations: Fitting and train-
units added comfort and were a defi- training sessions. The righ t knee was
ing the bilateral lower-limb amputee,
nite improvement. The man is now an unlocked and training continued,
in Bowker JH, Michael JW (eds): Atlas
unlimited community ambulator and with the patient progressing from the of Limb Prosthetics: Surgical, Prosthetic,
uses one cane for additional stability, parallel bars to two canes. Next, the and Rehabilitation Principles, ed 2.
especially when on uneven ground second knee was unlocked and train- Rosemont, IL, American Academy of
and in crowded places. ing continued with two canes. After Orthopaedic Surgeons, 200?., pp 599-
3 months of prosthesis use, the pa- 622. (Originally published by Mosby-
Case Study 2 tient was able to walk with one cane. Year Book, 1992.)
A 34-year-old man presented with bi- Torque absorbers were added to the 1 5. Moore TJ, Barron J, Hutchinson F III,
lateral transfemoral amputations sec- prosthetic systems, and the patient Golden C, Ellis C, Humphries D: Pros-
ondary to trauma from an automo- commented favorably about the ease thetic usage foUowtog major lower
bile accident. His right leg had been of taking longer steps and reported extremity amputation. Clin Orthop
amputated at the juncture of the dis- generally improved comfort. l 989;238:219-224.
tal and m iddle third of the femur, and 6. Inman VT, Ralston HJ, Todd R: Hu-
bis left leg had been amputated at man locomotion, in Rose J, Gamble JG
midfemur. He was in good physical
Summary (eds): Human Walking, ed 2. Balti-
more, MD, Williams & Wilkins 1994,
condition and had no other injuries. Numerous factors influence the suc-
pp 1-22.
The man was first seen by the ampu- cessful rehabilitation of the bilateral
tee rehabilitation team 4 months 7. Saunders JB, Inman VT, Eberhart HD:
lower limb amputee. A more distal
The major determinants in normal
postoperatively, at which time the re- level of amputation, particularly the
and pathological gait. J Bone Joint Surg
sidual limbs were contained in elastic preservation of the physiologic knee
Am l 953;35:543-558.
shrinkers and were well healed. H e joints, and the general strength and
8. Perry J(ed): Gait Analysis: Normal and
had a 10° flexion contracture on the health of the amputee are key predic- Pathological Function . Thorofare, NJ,
left side and a 5° flexion contracture tors for successful use of bilateral SLACK Inc, 1992.
on the right side. Initially, stubby prostheses. Careful attention by the
9. Gard SA, Childress DS: The influence
prostheses using rearward-facing feet prosthetist to the details of socket fit- of stance-phase knee flexion on the
attached with endoskeletal compo- ting, prosthesis alignment, and com- vertical displace ment of the trunk
nents were pcescribed to allow easy ponent selection following sound duri11g normal walking. Arch Phys Med
adjustment of length and alignment. prosthetic principles, in addition to Rehabil 1999;80:26-32.
The sockets were ischial contairunent the services of an experienced reha- 10. Gard SA, Childress DS: The effect of
designs with suction suspension . The bilitation team, will optimize the am- pelvic list o n the vertical displacement
initial rehabilitation plan called for bulation potential of the patient. of the trunk during normal walking.
gait training, minimizing the flex- Given these advantages and the deter- Gait Posture 1997;5:233-238.

I J. Gard SA, Konz RL: The influence of 16. Hoffman MD, Sheldahl LM, Buley KJ, 20. Wainapel SF, March H, Steve L: Stubby
prosthetic shock absorbing pylons on Sandford PR: Physiological compari- prostheses: An alternative to conven-
transtibial amputee gait. Gait Posture son of walking among bilateral above- tional prosthetic devices. Arch Phys
2001;13:303. knee amputee and able-bodied sub- Med Rehabil 1985;66:264-266.
12. Waters RL, Perry J, Chambers R: En- jects, and a model to account for the 21. Radcliffe CW: Above-knee prosthetics.
ergy expenditure of amputee gait, in differences in metabolic cost. Arch Prosthet Ortliot Int l 977; I: 146- I 60.
Moore WS, Malone JM (eds): Lower Phys Med Rehabil 1997;78:385-392. 22. Gard SA, Childress DS, Uellendahl JE:
Extremity Amputation. Philadelphia, 17. McCollough NC III, Harris AR, The influence of four-bar linkage
PA, WB Saunders, 1989, pp 250-260. Hampton FL: The bilateral lower-limb knees on prosthetic swing-phase floor
[3. DuBow LL, Witt PL, Kadaba MP, amputee, in Atlas of Limb Prosthetics: clearance. J Prosthet Orthot· 1996;8:
Reyes R, Cochran GV: Oxygen con- Surgical and Prosthetic Principles. St 34-40.
sumption of elderly persons with bi- Louis, MO, CV Mosby, 1981, 23. Trieb K, Lang T, Stulnig T, Kickinger
lateral below-knee amputations: Am- pp 417-422. W: Silicone soft socket system: Its ef-
bulation vs wheelchair propulsion. 18. Kruger LM: Stubby prostheses in the fect on the rehabilitation of geriatric
patients with transfemoral amputa-
Arch Phys Med Rehabil 1983;64: rehabilitation of infants and small
tions. Arch Phys Med Rehabil 1999;80:
255-259. children with bilateral lower limb defi-
522- 525.
14. Gonzalez EG, Corcoran PJ, Reyes RL: ciencies. Rehabilitation (Stuttg) 1990;
29:12-15. 24. Witso E, Ronningen H: Lower limb
Energy expenditure in below-knee
amputations: Registration of all lower
amputees: Correlation with stump J, Lowe
19. Crouse SF, Lessard CS, Rhodes
limb amputations performed at the
length. Arch Phys Med Rehabil 1974;55: RC: Oxygen consumption and cardiac University Hospital of Trondheim,
111-119. response of short-leg and long-leg Norway, 1994-1997. ProsthetOrthot Int
15. Huang CT, Jackson JR, Moore NB, et prosthetic ambulation in a patient 2001;25: 181 - 185.
al: Amputation: Energy cost of ambu- • with bilateral above-knee amputation: 25. Wu Y, Krick H: Removable rigid dress-
lation. Arch Phys Med Rehabil 1979;60: Comparison with able-bodied men. ing for below-knee amputees. Clin
18-24. Arch Phys Med Rehabil [990;71: Prosthet Orthop 1987; 11 :33-44.
313-317.

Int i
Expe:
tal w
cise.
and ·
tions
physi
healtl
mote
self-c
risk
such
Man)
reatic
• I cepti<
comi::
Je,ss t
McKi
con ti:
corni::
boxin
putee
may
mane
tatior
achie
joy SJ
tivitie
A
tees s
partic
activi
that d
to ru
the a:
the ri
ity m
pa ran
tion c
Prostheses for Sports and
Recreation
David Alan Boone, CP, MPH
Introduction
Experts agree that physical and men- artificial limb cannot offer the same regimens and lifestyle choices, the
tal well-being are enhanced by exer- complex integration of power and prosthetist and amputee must balance
cise. The US Public Health Service control as the natural limb, but a suit- the systemic benefits of activity with
and various public health organiza- able prosthesis allows many amputees its potential health risks.
tions highly recommend regular' to enjoy participatory sports and The prosthesis optimized for recre-
physical activity to help combat other physical activities. Understand- ational use is finely tuned to both the
health concerns. Physical activity pro- ing the physical characteristics of the specific function required and the us-
motes independence and increases missing limb and how it functioned is er's capabilities. Realistic performance
self- confidence while decreasing the the first step in determining what a goals should be set in this context. It
risk of many physical pathologies, prosthesis should offer. A higb- may be more encouraging for the am-
such as cardiovascular disease. 1- 7 quality, properly fitted prosthesis is putee to reach lesser goals quickly and
Many amputees enjoy sports and rec- critical to physical activity. This chap- to then set more ambitious goals as
reational activities, and some with exter presents principles to help guide incremental improvements in perfor-
ceptional physical abilities excel in the design of prostheses suitable for mance are attained.
competitive sports, running 100 m in sports and recreational activities.
Jess than 11 seconds, climbing Mt.
McKinley or Mt. Everest, traversing
Physical Preparation
continents on foot and bicycle, or
Initial Evaluation Creation of a sports prosthesis should
competing in professional baseball or As part of the physical evaluation and proceed in conjunction with the am-
boxing. Although the world-class am- history, the cause of the amputation putee athlete's general physical prepa-
putee sprinter or marathon runner must be considered. For example, iJ ration and conditioning. Ideally, a
may attain the pinnacle of perfor- the limb loss was due to complica- comprehensive program of physical
mance, most individuals with ampu- tions of vascular insufficiency, the pa- fitness should begin under the direc-
tations do not aspire to this level of tient may not have engaged in any tion of a physical therapist who is fa-
achievement. They simply want to en- significant physical exertion for some miliar with the amputee's unique situ-
joy sports and other recreational ac- time. It is equally important to recog- ation. It is important to communicate
tivities with family and friends. nize that increased physical activity to the amputee that the prosthesis it-
A 1980 survey of lower limb ampu- can raise health risk levels in certain self is not the sole means to attaining a
tees suggested both a strong desire to populations.6 Pinzur and associates,9 higher activity level. Simply incorpo-
participate in sports and recreational for example, suggest that dysvascular rating a sprinting foot into a lower
activities and the need for a prosthesis amputees with severe peripheral vas- limb prosthesis will not allow the indi-
that did not limit the amputee's ability cular insufficiency function at near- vidual to run; the prosthesis is merely
to run or move quickly.8 Evaluating maximtun capacity when simply am- an assistive device that will facilitate
the amputee patient and prescribing bulating. Patients with diabetes and use of whatever strength and stamina
the right prosthesis for athletic activ- peripheral neuropathy can develop the individual achieves through phys-
ity must go well beyond the standard potentially life- and limb-threatening ical conditioning. When the amputee
parameters associated with ambula- ulcers because of excessive skin load- has developed the requisite physical
tion and vocational requirements. An ing. When recommending exercise capabilities, the prosthetist can opti-

require a higher act1v1ty level than

golf, but both are high-activity sports.
Runners move quickly for a relatively
short period of time, whereas golfers
move more slowly over a period of
several hours; each sport may require a
simila1· number of steps.
Functional demands are more im-
portant in prosthesis design than ac-
tivity level. The recreational jogger re-
quires a prosthesis that will absorb
the impact of initial contact and load-
ing response, support the body weight
through midstance to allow a long
stride length on the sound side, and
8
· --
,.__ provide some measure of propulsive
thrust at the end of stance. Golf has
an entirely different set of functional
demands. Although golf may not re-
Figure 1 M any sports do not requ ire use of a prosthesis. A, Bilateral forearm crutches
quire the same cardiovascular de-
worn in competitive soccer. B, Alpine skier using outriggers. (Courtesy of Steve Wilber,
Seattle, WA.)
mands as jogging, the golfer must be
able to endure long periods of stand-
ing, maintain overall stability when
mize the prosthesis so the individual An amputee who chooses not to twisting during swings, and ambulate
can increase speed and distance. Max- wear a prosthesis may wear a residual safely over uneven terrain and in-
imum sports performance may re- limb protector, a thin plastic shell clines.
quire modified or specialized compo- similar to the prosthetic socket, gener-
nents or significant deviations from ally incorporating a simple belt or Alignment
F
standard alignmen l lech11iqu1::s lo help sleeve suspension that protects the Alignment is a key element for opti· c
improve interlimb symmetry and run- limb from impact or abrasion. A sim- ma! functioning of lower limb pros- a
ning velocity. 10 ple flexible foam or rigid plastic shell theses. Socket and shank alignment 7
r,
is especially useful in high-speed 'critically affects the wearer's comfort
sports, such as snow skiing, where and dynamic performance by altering
Choosing Whether to high-impact falls are not uncommon. the manner in which the weight· a
Use a Prosthesis Use of a prosthesis may be hazard - bearing load is transferred between
An amputee can participate in sports ous to others during some activities. the supporting foot and the residual c
without a prosthesis. Some amputee For example, an amputee playing soc- limb. Alignment of the lower limb b
swimmers, for example, use a pros- cer or a competitive contact sport prosthesis for sports activities may b
thesis only to reach the pool or shore- such as football may be required to differ significantly from that which is t
line, removing it before entering the cover the prosthesis with additional optimal for other activities of daily c
water, whereas fly fishers may find foam padding to protect the other living. Water and snow skiing, for ex· s
that using a prosthesis is safer and players. ample, require increased ankle dorsi- v
makes wading less strenuous. Some flexion (Figure 2) . A prosthesis opti-
mally aligned for these sports will not
organized sports for amputees, such Design
as soccer, regulate the use of prosthe- function well for general ambulation,
ses, requiring participants to use bi-
Considerations so either a special-use prosthesis or
lateral fo rearm crutches and forgo the Activity Level interchangeable components will be
use of a prosthesis on at least one re- Any sports prosthesis should be de- required. 1
sidual limb (Figure 1, A) . Amputee signed to withstand the level of de-
athletes parti0ipating in Alpine skiing mand t he athlete will place on it.
Dynamics of the Lower
in the Paralympic Games use single Recent long-term monitoring of am- Limb
skis (for single-leg amputations), out- bulatory activity has demonstrated The human leg is a complex instru· lJ
riggers, or prostheses (Figure 1, B), that some assumptions about activity ment offering dynamic shock absor_p- t
and individuals with arm amputa- levels may be inaccurate. 11 For exam- tion, adaptation to uneven terrain, 0
tions forgo the use of poles. ple, running is commonly believed to torque conversion, knee stabilization,

Chapter 50: Prostheses for Sports and Recreation 635
that cause soft-tissue damage. For

most sports and recreational activi-
ties, the prosthesis shou/d be designed
to reduce impact and its associated
socket p ressure and shear. The follow-
ing discussion begins with the foot as
the first contact with the ground and
then considers the more proximal ele-
ments of the prosthesis.
Influence of the Foot on

Impact Reduction
The heel of the foot can absorb some
portion of the impact d uring ambula-
tion and slow jogging, but this is
speed dependent. Data show that in
Figure 3 Competitive spri nter wearing no namputee athletes during normal
foot configured without a heel. (Courtesy
ambula tion, at a speed of 80 m/min, a
of Ossur, Aliso Viejo, CA.)
full heel strike occurs during initial
contact. As the ambulation speed in-
these forces may become exponen- creases to a fast walk or slow jog,
tially higher because of increased im- at 140 m/min, the middle portion of
pact loads. The residual limb is sub- the foot becomes the primary initial
ject to pressure and shear forces; both contact point and the heel has mfo-
increase during high-impact activity. imal effect. Once running speed
Shear stresses and/or pressure on the (180 m/min) is achieved, heel contact
skin can cause occlusion of the blood is virtually eliminated. 16 Similar data
flow. have been demonstrated in studies of
Figure 2 Prosthesis adjusted to allow in-
The greater the shear fo rces gener- prosthetic limb kinematics. 17
creased ankle dorsiflexion for sports such
as water and snow skiing. (Courtesy of ated with a prosthesis, the lower the Clinical application of these data
The Adaptive Sports Association, Du- pressure required to cause blood flow helps specify the durometer of the
rango, CO.) heel of the prosthetic foot for trans-
occlusion and resultant tissue break-
tibial amputees. Shock absorptio n
down.13 The cyclic shear stress that
through compression of the prosthetic
automatic lim b lengthening and inevitably occurs within a prosthetic
heel or plantar fl exion bumper is very
shortening to diminish the arc of the socket can cause a blister to form
important for a recreational walker
center of gravity, transfer of weight- within the epidermis or create an
who has no intention of jogging o r
bearing forces, and reliable weight- abrasion on the skin surface. Adher-
running; heel components also con-
bearing support. 7 A lower limb pros- ent scar tissue, common after trau-
trol the rate of foot plantar flexion
thesis cannot fully replicate these matic am putatio ns, can create shear during loading response in much the
critical functions, but a properly de- stress adjacent to the area of amputa- same way as does eccentric lengthen-
signed and fitted prosthesis will pro- tion, resultfog in skin tension that can
ing of the dorsillexor group in the nat-
vide a reliable level of each. 12 cause blanching or even cell rup- ural foot. When the amputee begins
ture. 14 One investigation of an in- jogging or running, however, the heel
Impact Reduction During strumented patellar tendon-bearing component may not be loaded as
Loading prosthetic socket demonstrated that fully, so its shock-absorbing value de-
Impact on the residual limb begins maximal pressure and resultant shear creases. This explains why the an1pu-
when the foot contacts the ground. stresses shifted locations between the tee sprinter prefers a foot without a
These forces are relayed through the loading phase of stance and the latter heel, even though this configuration is
structure of the prosthesis to the re- phases of the gait cycle. 15 This is be- unsuitable for walking (Figure 3).
sidual limb and are greatest during lieved to be a result of the dynamic As the amputee enters midstance
loading response while walking, d ur- movement of the residual limb within on the prosthesis, the foot should ac-
ing pushoff and landing on the pros- the socket. comm odate uneven terrain and help
thesis when jumping, and during the As an individual's activity level in- control advancement of the tibia. Tib-
contact phase of a new stride while creases, both socket pressure and ial advancem ent that is too abrupt re-
running. During sports activities, shear forces can easily rise to levels sults in resistance to the knee Oexion

t
f
Figure 6 Flexible plastic inner socket Fi!
supported by a rigid external frame. A to
flexible brim on the transfem oral pros- in
thesis increases comfort during high ac- th
Figure 5 Skin grafts and lack of soft tis-
tivity. er
sue reduce limb tolerance for shear.
ti(
Influence of the Shank on socket brim. The amputee's comfort ~

Figure 4 Shock-absorb ing pylons reduce can be increased by the use of a flexi-
the forces transmitted to the residual Impact Reduction
ble plastic inner socket supported by
limb and allow the prosthesis to continue The prosthesis can continue to absorb
t o absorb impact after the foot has
a rigid external frame. This combina- s~
impact after the foot has reached its tion mruntains the structural weight- SC
reached its limit.
limit if there is a shock-absorbing py- 3Upporting integrity of the socket
lon between the foot and socket. while increasing the range of hip mo-
moment, increasing the forces on the These pylons may be integrated tion because of the flexibility of the
residual limb within the socket. A new within the shin/ankle/foot compo- proximal socket (Figure 6).
prosthesis should be aligned and ad- nent or added as independent struc-
justed based on evaluation of its per- tures separate from the foot (Figure Reduction of Rotational
a1
formance as the amputee uses it on 4). Most shock-absorbing pylons re- Forces
g<
surfaces similar to those that will be quire adjustment by the prosthetist to Absorption of transverse plane rotary w
encountered in athletic activity. Activ- provide the optimal amount of verti- forces in the residual lower limb oc-
ities such as hiking that include tra- cal travel for each individual. curs when ankle pronation and supi·
versing uneven terrain may require nation allow lower limb rotation as
use of a multiaxial ankle, which al- Influence of the Interface on the foot contacts the ground. A pros·
lows the prosthetic foot to conform to Impact Reduction thetic torque absorber component
irregular surfaces, thus reducing the Amputees with conditions such as can be provided that will allow inter·
forces transferred to the residual limb. bony residual limbs, skin grafts, or nal and external rotation between
An articulated foot should be consid- adherent scars will have a reduced tol- the socket and tJ1e foot. Although
ered when reduction of the knee erance for shear (Figure 5). When multiaxial ankles offer some rota·
flexio n moment on a transfemoral athletic activity increases multidirectional movement, a separate torque·
prosthesis is desirable. When the ar- tional forces that give rise to pressure absorbing component does this most
ticulated foot plantar flexes rapidly to and shear stresses, a socket liner made effectively. Some amputee golfers re·
the ground during loading response, from an elastomeric gel is often rec- port that these components help
the ground-reaction force vector ommended. For transfemoral ampu- them achieve a smooth swing and
moves forward quickly and thereby tees, special consideration should be follow-through and also reduce the
prevents uncontrolled knee flexion given to the ischial tuberosity area uncomfortable rotational shear that
under weight bearing. and the proximal tissue along the would otherwise occur between the

Figure 8 Competitive runner using dynamic-response foot with a spring keel extending
into t he shin region. The increased flexibility offered by this combination is generally
preferred by advanced runners. (Courtesy of Ossur, Al.iso Viejo, CA.)
Figure 7 Gol fer wearing prosthesis with

General-Use Versus from participation altogether.20 An
torque absorber component that allows
amputee planning to participate in
internal and external rotation between• Activity-Specific downhill skiing on a regular basis re-
the socket and the foot. Torque absorb-
ers are particularly important for activi- Prostheses quires a custom-designed ski prostl1e-
t ies requiring transverse plane move- sis to ensure maximwn personal
One consideration is whether a pros-
ments. (Courtesy of Ohio Willow Wood, safety and control on the slopes. Al-
Mt. Sterling, OH.) thesis designed for sports activities can
also double as an everyday limb. Some pine skiing on a prosthesis intended
prostheses can be designed to allow only for walking is ilie functional
the amputee to participate safely and equivalent of skiing in sneakers. The
skin of the residual limb and the optimal design of an activity-specific
socket (Figure 7). comfortably in a relatively wide range
of activity, including selected sports. prosthesis facilitates full participation
Limb Acceleration Options like elastomeric gel liners that in the desired activity.
provide the socket comfort required In some instances a comfortable
for High Activity socket suitable for daily use can be
during everyday tasks may suffice for
The choice of foot affects the ability some recreational activities. The use of coupled with interchangeable distal
to propel the limb forward. Enoka an optimal prosthetic foot may allow components that have been selected
and associates 18 studied the forces the amputee to walk faster and achieve to facilitate different tasks. For exam-
generated while running and jumping a more equal step length on both sides, ple, a quick-release coupler can be
with a prosthesis. The large ground- facilitating recreational activity and provided to permit interchanging
reaction forces demonstrated during routine walking. 19 Carefully selected knee and foot/ankle components.
these activities led to the design of a dynamic feet, aligned for comfort and This alternative, when appropriate,
prosthetic foot that could store the efficiency during walking, can some- can be more economical than individ-
energy placed on it during weight times function adequately for inter- ual prostheses (Figure 9).
bearing and release a portion of that mittent, moderately paced jogging.
energy later in the gait cycle to assist A sports-specific prosthesis is usu-
in propelling the limb forward during
Other Considerations
ally necessary for maximum perfor-
unweighting. Such dynamk-response mance and personal safety. Despite Most amputees want to be more ac-
feet vary widely in design, function, strong evidence about the benefits tive and to participate in more vigor-
and cost. Fast-paced joggers and ad- arising from exercise as part of a ous activities. 21 Because of tl1e lack of
vanced runners often prefer a high- healthy lifestyle, funding for sport- conclusive scientific evidence to sup-
profile foot that incorporates a flexi- optimized prostheses is often denied, port the choice of prostheses and
ble shin portion. The longer spring thereby limiting the amputee to the components to permit such increased
length of these components has been use of a general-purpose prosthesis activity, the amputee and prosthetist
shown to offer maximum capacity for for sports participation and some- must rely on their own experience. 22
energy storage and return (Figure 8). times forcing the amputee to refrain The prostbetist must clearly under-

Figure 9 Amputee usi ng a quick-release

coupler to facilitate getting out of an au-
tomobile.
Figure 10 This single-purpose ski foot at- Figure 11 This athlete uses a custom foot
taches directly to th e ski binding, elimi- designed for rock climbing. (Courtesy of
nating the need for a ski boot. Prosthetic Research Study, Seattle, WA.)
stand the functional and biomechani-
cal demands of a specific sport when
recommending a prescription to en- tached to the ski bindings. Cyclists result in adequate design but also
sure that the functional characteris- may use a similar system of binding present some risk to the amputee.
tics of the components meet these de- the prosthesis directly to the bike
mands. pedal. T hese si ngle-purpose designs
T he final weight of the prosthesis
Waterproof
not only eliminate excess weight but,
is another important consideration more importantly, also enhance en- Prostheses
and is influenced by the desired activ- ergy transfer to the sporting equip- immersion of a prosthesis in water
ity. Prosthetic weight affects the dura- ment for more efficient performance presents unique requirements for du-
tion of a demanding activity and has (Figure 10). rability, comfort, and propulsion.
been demonstrated to be most impor- Most prostheses will tolerate occa-
Some sports have very specific de-
tant at higher velocities. The location sional, nominal exposure to moisture,
mands t hat can be addressed only by
of mass within the prosthesis is often particularly when protected under a
unique custom components. Com-
more critical than the overall weight, layer of clothing. A specialized water-
mercially produced prosthetic feet are
with distally placed mass demonstrat- proof design is necessary when the
unsuitable for rock climbing because
ing more negative effects. The pros- amputee will have regular exposure to
the toe is not rigid enough to support
thetic design effort should therefore saltwater or fresh water, especially if
the full body weight when only that
focus on keeping the necessary mass complete immersion is possible, al-
in a more proximal location whenever portion of the prosthesis is in contact
though many amputees participating
feasible.23 with the rock face. The shape and tex-
in water sports may wear the prosthe-
ture of a climbing foot can be cus- sis primarily to reach the water's edge.
Single -Purpose Prostheses tomized to increase performance with The recreational water-skier, for in-
Participation in most sports can be added traction and the ability to fit in stance, may wear the prosthesis to
facilitated by adaptations of conven- small cracks and crevices (Figure 11 ). ambulate safely on the dock and on
tional socket designs combined with Design and fabrication of func- the boat, then remove it to ski. It may
commercially available components, tional specialty items by prosthetists be possible to modify the everyday
but some activities are best accom- and amputees is sometimes the only prosthesis to make it resistant to
plished with unique custom-designed practical option. Because of the lack splashes but not fully waterproof.
components. For example, amputee of adequate facilities and professional The simplest way to protect the
snow skiers may use a prosthetic "ter- expertise for clinical and practical prosthesis is to purchase a commer-
minal device" modeled after the sole evaluation of prototype devices, the cially available waterproof cover, such
of a ski boot that can be directly at- current trial-and-error process can as those intended to be worn over leg

Summary
Prosthetic options for sports activities
are rapidly evolving, anci the prosthe-
tist is generally the best source for up-
to-date information. The amputee's
needs and desires should be clearly
understood and the functional de-
mands of the activity determined be-
fore the prescription is developed. In
some instances, the prosthetist can
figure 12 Prostheses used for water im- design a device that supports both ev-
mersion should have neutral buoyancy. eryday ambulation and less demand-
This model fills with water and drains au-
tomatically when the limb is no longer ing athletic activities. At other times,
immersed. (Courtesy of Prosthetic Re- the amputee will require a prosthesis
search Study, Seattle, WA.) optimized for a specific activity. Using
a prosthesis for activities that it was
Figure 13 Specialty ankle with flipper at- not designed to accommodate can
tached to the limb locks in a plantigrade cause physical injury to the amputee
position to allow ambulation on land and as well as premature structural failure
locks in ful l plantar flexion for swimming. of the device. A properly designed
(Courtesy of Rampro, Leucadia, CA.)
prosthesis can substantially expand
the opportunities for physical fitness
thigh is sometimes sufficient to keep and personal reward for many per-
water out of the interface between sons with amputations, allowing them
limb and socket. Knee sleeves aid sus- to engage safely in a broader range of
pension while still allowing adequate activities.
range of motion for swimming or
wading. References
Many options exist for a special-
I. Pate RR, Pratt M, Blair SN, et al: Phys-
ized prosthesis strictly for water use. ical activity and public health: A rec-
Because metal, foam, and even plastic ommendation from the Centers for
and composite materials may have Disease Control and Prevention and
adverse reactions to fresh water or the American College of Sports Medi-
saltwater, however, the prosthetist cine. JAMA 1995;273:402-407.
should consult with the component 2. Healthy People 2000: National Health
supplier's engineering department to Promotion and Disease Prevent,ion Ob-
avoid structural failure of water jectives. Washington, DC, US Public
Figure 14 This waterproof peg-style leg limbs. Heal th Ser vice Department of Health
is suitable for both ambulation and swim- aJ1d Human Services, 1991 D HHS Pub
Propulsion in the water is substan-
ming. (Courtesy of Prosthetic Research No PHS 91 =502 12.
Study, Seattle, WA.)
tially enhanced by adding a flipper to
3. Physical activity and cardiovascular
the limb. Two primary methods pro-
health: NIH Consensus Development
vide this capability. First, some spe- Panel on Physical Activity and Cardio-
casts. These products are designed for cialty ankles lock in neutral or in full vascular Health. JAMA 1996;276:
short-term use and are not suitable plantar flexion, allowing regular am- 241- 246.
for repeated use. A prosthesis com- bulation when upright as well as use 4. Physical Activity and Health: A report
pletely covered with an airtight seal of the flipper when swimming (Figure of the Surgeon General. Atlanta, GA:
will tend to be buoyant, which can 13). The second approach uses a U.S. Department of Health and Hu-
make some activities, such as swim- modified flipper encasing the distal man Services, Centers for Disease
ming underwater, difficult. If swim- socket, which allows a more natural Control and Prevention, National
Center for Chronic Disease Prevention
ming or snorkeling is anticipated, kick and reduces the torque on the re-
and Health Promotio n, The Presi-
then the prosthesis should be de- sidual limb. Incorporation of a water- dent's Council on Physical Fitness and
signed to maintain neutral buoyancy proof peg-style foot allows reasonable Sports, 1996. Available at http://
(Figure 12). Adding a rubber suspen- ambulation out of the water or in www.cdc.gov/nccdpbp/sgr/sgr.htm.
sion sleeve over the socket an'd distal shallows (Figure 14). Accessed May 19, 2004.

5. Williams MA: Cardiovascular risk- ity monitor: Long- term, continuous 18. Enoka RM, Miller DI, Burgess EM:
factor reduction in elderly patients reco rding of ambulatory function. Below knee amputee running gait. Am
with cardiac disease. Phys Ther 1996; J Reha.bi/ Res Dev l 999;36:8-18. J Phys Med 1982;61:66-84.
76:469-480. 12. Donatelli R: The Biomechanics of the 19. Mizuno N, Aoyama T, Nakajima A,
6. Hahn RA, Teutsch SM, Rothenberg Foot and Ankle. Philadelphia, PA, FA Kasahara T, Takami K: Functional
RB, Ma rks JS: Excess deaths from nine Davis, 1990, pp 9-27. evaluation by gait analysis of various
chronic diseases in the United States, 13. Bennett L, Kavner D, Lee BK, Trainor ankle foot assemblies used by below
1986. JAMA 1990;264:2654-2659. FA: Shear vs pressure as causative fac- knee amputees. Prosthet Orthot Int
7. Kochersberger G, McConnell E, tors in skin blood flow occlusion. Arch 1992;10:174- 182.
Kuchlbhatla MN, Pieper C: The reli- Phys Med Rehabil 1979;60:309-314. 20. Carroll K: Adaptive prosthetics for the
ability, validity, and stability of a mea- lower extrem ity. Foot Ankle Clin 2001;
14. Sanders JE, Daly CH, Burgess EM:
sure of physical activity in the elderly. 6:371-386.
Interface shear stresses during ambu-
lation with a below knee prosthetic 21. Burgess EM, Hittenberger DA, Fors-
793-795.
limb. J Rehabil Res Dev 1992;29:l-8. gren SM, Lindh D: The Seattle pros-
8. Kegel B: Physical fitness: Sports and
15. Sanders JE, Dickson L, Dralle A, Oku- thetic foot: A design for active sports.
recreation for those with lower limb
mura R: Interface pressures and shear Preliminary studies. Ort/10t Prosthet
amputation or impairment. J Rehab
stress at thirteen socket sites on two l 983;37:25-3 1.
Res Dev Clin Suppl 1985;1 :1 - 125.
persons with transtibial ampu tation. 22. Hafner BJ, Sanders JE, Czerniecki J,
9. Pinzur MS, Gold J, Schwar tz D, Gross
N: Energy demands for walking in J Rehabil Res Dev l 997;1:19-33. Fergason J: Energy storage and return
dysvascular amputees as related to the 16. Lehmann JF, Price R, Fergason J, Oku- prostheses: Does patient perception
level of amputation. Orthopedics 1992; mura R, Koo n G: Effect of prosthesis correlate with biomechanical analysis?
15:1033-1036. resonant frequency on metabolic effi- Clin Biomech 2002; 17:325-344.
10. Burkett B, Smeathers J, Barker T: Opti- ciency in trans-tibial amputees. 23. Lehman JF, Price R, Okumura R,
m izing the trans-femoral prosthetic J Rehabil Res Dev R&D Progress Reports Questad K, Lateur B, Niegretot A:
alignment for ru nning, by lowering 1999. Mass and mass dist ribution of below
the knee joint. Prosthet Orthot Int 17. Buckley JG: Sprint kinematics of ath- knee prostheses: Effect on gait efficacy
2001;25:210-219. letes with lower limb amputations. and self selected walk ing speed. Arch
l I. Coleman KL, Smith DG, Boone DA, Arch Phys Med Rehabil I 999;80: Phys Med Rehabil 1998;79:162-168.
Joseph AW, Del Aquila MA: Step activ- 501-508.

Physical Therapy for Sports ~nd
Recreation
Int roduction
Advances in sw-gical procedures, mits amputees of all ages to vary their the pool deck. Mountain climbers
postamputation rehabilitation, and cadence and negotiate obstacles. Ac- typically have needs specific to the
prosthetic technology have afforded tive amputees demand restoration be- type of climbing and level of amputa-
amputees of all levels more opportu- yond simple walking, embracing the tion. Usually, the demand for these
nities to participate in a variety ot goals of recreational and, occasion- specialty devices is so small that cus-
recreational and competitive sports. ally, competitive sports. Rehabil- tom prostheses must be fabricated.
Surgical procedures have evolved, en- itation must meet the challenge of Fortunately, amputees new to a sport
couraging surgeons to consider opti- restoring the amputee's physical capa- can access valuable print and elec-
mum preservation of muscle function bilities to a level that permits maxi- tronic information about prosthetic
by myodesis, preserve bone length, mum use of the prosthesis. designs that have worked for others.
and create end-bearing residual limbs Prostheses available today easily
when possible, improving patients' eclipse the Limited choices of the past.
athletic capabilities. For example, ath- Improved socket designs permit im-
Exercise Activities
letes with knee disarticulations have proved muscular function within the Exercise activities can be divided into
repeatedly demonstrated greater socket. Socket interface systems re- four distinct categories: (1) restor-
speed in sprint racing than have duce the compressive and shear ative, (2) regimented, (3) leisure, and
transfemoral amputees. Now the con- forces, thereby increasing comfort (4) competitive. Many recreational
sensus among those involved in track and reducing the risk of skin irrita- sports enjoyed by amputees, such as
sports is that maintaining bone length tion. More responsive knee systems walking, swimming, cycling, or golf,
and preserving or restoring muscle permit increased mobility for trans- encompass a.LI four exercise catego-
insertions, coupled with end-bearing femoral amputees. The wide variety ries. As an example of a restorative ex-
capabilities, offers a sprinter with of foot/ankle systems allows amputees ercise, walki11g is frequently used for
knee disarticulation a clear advantage. a choice of components that have the rehabilitation after an injury or ill-
The same is true for a Syrne ankle dis- potential to improve performance, ness. Having a patient ambulate in the
articulation compared with a trans- whether the goal is to run faster, im- hospital room, down the hall, or in
tibial amputation. prove agility with multidirectional the rehabilitation center to increase
Rehabilitation methods have also sports, or adapt to uneven ground strength and endurance are examples
progressed, including gait training with a firm footing for sports such as of walking as a restorative exercise.
techniques that have improved walk- golf. Regimented exercise is commonly per-
ing efficiency. 1•2 Moreover, functional In addition, many specialty pros- formed after discharge from rehabili-
progression techniques offer ampu- theses are available, either from man- tation as a means to maintain fitness
tees the ability, through multidirec- ufacturers or on a custom basis for at home or a health club. Exercise
tional strengthening exercises, to re- specific sports. Many amputees like to walking may include work on a tread-
educate the neuromuscular system to swim but have different needs for get- mill for 30 minutes, three times a
better control movement in all planes. ting into and out of the water. For ex- week, at 60% to 70% of maximal oxy-
Closed kinetic-chain activities may ample, scuba divers do not need the gen uptake3 or at a target heart rate to
also improve control of the prosthesis ability to walk, whereas recreational monitor progress or to maintain de-
within the socket. Speed training per- swimmers may want to walk around sired levels of physical conditioning.

Leisure exercise is often used to relax that fall short of the amputee's actual age groups. Thirty percent of patients
and reduce stress, often while simul- capabilities or exclude the amputee attributed the delay in returning to ac- T
taneously socializing with family and from higher-level tasks, the amputee's tivity to prosthetic fitting and comfort
friends. An example is a group that body image, activity level, or motiva- problems, prolonged recovery, phan-
walks together while chatting. Com- tion to pmsue healthful activities may tom pain, and residual limb pain, al- A
petitive exercise typically requires be jeopardized.5 -7 though only 13% found that discom- s·
more intensive training than the pre- fort interfered with their return to G
vious three categories of exercise, and activities. Only 20% of all respondents
the participants have clearly estab-
Recreational Pursuits experienced no delay in their return to v
lished goals. Race walking is an exam- of the Lower Limb activities. c
ple of competitive exercise. Amputee The recreational activities most B
To one degree or another, all ampu- commonly enjoyed by elderly ampu-
tees experience restorative exercise as Gailey and associates8 •9 reported the tees are golf, swimming, fishi ng, walk- B
they work through their rehabilita- results of a questionnaire exploring ing, dancing, boating, bowling, and
four topic areas: (1) the amputee B
tion. More motivated individuals will bicycling. The most popular recre-
continue with some form of regi- profile, (2) prosthetic management, ational actJV1t1es for amputees
mented exercise for a period of time (3) degree of participation in recre- younger than 49 years are almost
after discharge from the hospital, ational activities, and (4) the ampu- identical. A comparison was made
whether at a rehabilitation center, a tee's perception of rehabilitative needs with the National Sporting Goods As- t:
fitness center, or independently at and suggested improvements fo r the sociation's (NSGA) annual survey of v
home. The goal of the rehabiJ itation rehabilitation team. A total of 1,214 20,000 Americans regarding their par- f.
team should be to assist the amputee questionnaires were analyzed from 41 ticipation in sports. 13 The 1991 NSGA a
in the transition to leisure exercise or, individuals with hip disarticulations, report indicates that Americans age a
in some cases, competitive sports. This 592 transfemoral amputees, 492 trans- 55 years and older ranked the follow- a
does not mean that the team is in- tibial amputees, 23 individuals with ing sports in order of popularity: [
volved every step of the way; rather, it Syme ankle disarticulations, 43 bilat- walking, fishing, swimming, bicy- a
is the team's responsibility to educate eral transtibial amputees, and 23 bilat- cling, golf, exercise with equipment,
and motivate the amputee. Education eral transfemoral amputees. The mean bowling, and camping (Table 1). Not "
includes the prescription of a person- age of the total sample population was surprisingly, amputees and nonampu-
alized regimented exercise program 48 years. This population does not re- tees enjoy exactly the same recre-
that includes precautions about activ- flect the usual distribution of amputa- ational sport activities, regardless of
ities that could lead to injury as well as tion etiologies in that 58% of all re- t~e level of amputation. Running is
contacts for support groups and ap- spondents lost their limb because of not within the top 10 activities with
propriate special-interest organiza- traw11a, 20% from vascular disease, either group, yet it is the one skill
tions. Equally important is motivating 13% from tumor, and 4% because of most amputees long to possess.
the amputees to meet long-term goals congenital deficiencies. 10 • 12 This dif- Participation by amputees in recre-
by inspiring them to pursue a lifelong fers from conventional estimates, ational activities across the life span
program of leisure activities or recre- which suggest that 70% to 90% of am- varies only slightly from that of the
ational sports. putations in Western countries are re- total population, with 76% reporting
Younger amputees usually return lated to vascular disease, 4% are tumor part1c1pation and 20% reporting
more successfully to their premorbid related, and 4% are congenital in na- none. The total number of days per
level of activity than do elderly ampu- ture, with the balance ( up to approxi- week that partkipation in recre-
tees. Health care workers tend to gain mately 20%) the result of trauma. An- ational activities occurs indicates that,
satisfaction from seeing a young per- other bias in the study is that those regardless of age, those who do par-
son return to sports after a debilitat- who participated in recreational activ- ticipate maintain a weekly frequency
ing incident. Unfortunately, the same ities were more likely to complete the similar to that of the general popu-
stimulus is not always present with questionnaire, suggesting that trau- lation, with 60% participating l to
older patients, even though these pa- matic amputees are more inclined to 4 days per week and 14% participat·
tients generally perceive their health participate in recreational activities ing 5 to 7 days per week.
to be good. 4 Preconceived notions than are amputees who lose a limb be- In most cases, these sports are not
about a particular age group's limita- cause of vascula1· disease. taxing to the residual limb and can be
tions and abilities are frequently an In this population, approximately enjoyed by most younger and older
obstacle to be overcome by health 60% of previously active amputees re- amputees without placing tl1e skin at
care providers responsible for setting turned to recreational activities within risk. In some instances, minor adap-
long-term rehabilitative goals. If the the first year after amputation. There tations by the amputee may be neces·
rehabilitation team establishes goals was no appreciable difference between sary, depending on the type of ampu-

Chapter 51: Physical Therapy for Sports and Recreation 643
TABLE 1 Recreationa l Activities in Order of Participation Popularity
Amputees Amputees Amputees Amputees Amputees Able-bodied

All amputees 0- 19 years9 20-29 years 30-39 years 40-49 years 50+ years All able-bodied 13 55+ years13
swimming Swimming Swimming Swimming Swimming Golf Walking Walking
Golf Fishing Dancing Fishing Golf Swimming Swimming Fishing
Fishing Walking Fishing Walking Fishing Fishing Bicycling Swimming
Walking Bicycling Boating Dancing Dancing Walking Camping Bicycling
Dancing Bowling Bicycling Boating Walking Dancing Fishing Golf
Boating Dancing Walking Bicycling Boating Boating Bowling Exercise w it h
equipment
Bicycling Boating Golf Golf Bicycling Bowling Exercise with Bowling
equipment
Bowling Basketball Snow skiing Snow skiing Snow skiing Bicycling Basketball Camping
tation and the level of athleticism at increases to approximately 50%. Only be extremely informative, 19% some-
which the sport is played. The reasons 13% of amputees never experience what informative, and 51 % uninfor-
for limiting participation in recre- any prosthetic problem during physi- mative. Prosthetists were perceived as
ational activities were similar across cal activity. 8 •9 Many amputees view more knowledgeable, with 15% being
all age groups. The inability to ru~ their prosthesis as part of their ath- extremely informative, 32% some-
and to jump, decreased endurance, letic equipment and learn to antici- what informative, and 31 % uninfor-
increased fatigue, decreased balance, pate problems. Persistent prosthetic mative. Amputees who received phys-
and reduced speed of locomotion problems, however, can often be re- ical therapy reported that only 6% of
were also problems found to impede duced with a variety of adaptations or physical therapists were extremely in-
competition on an equal basis with ingenious modifications to meet the formative, 14% were somewhat infor-
nonamputees, as was the inability to demands of a particular sport. mative, and 24% were uninforma-
regain the level of skill achieved be- The most common prosthetic tive.8 •9
fore amputation. problem is skin irritation or break- Of aU the questions asked, the one
The results from the amputee sur- down. Approximately 55% of all am- that may best represent the positive
vey suggested that older amputees putees experience skin problems with attitude of many amputees is: When
may be more willing to return to activities of daily living or during rig- particiipating in organized sports with
prior activities than are younger am- orous activity, the only d ifference be- nonamputees, should allowances be
putees. The amputee survey also ing the frequency with which the made? Fifty-four percent responded
noted that three responses were given problems occur. Interestingly, 26% of no, and 30% said yes. This response
with similar frequency: embarrass- amputees experienced a decrease in may be extrapolated to mean that am-
ment, lack of instruction, and lack of skin irritation when they changed putees. do not want the rules changed,
supportive organizations to join. from a traditional to a contemporary they just want quality prostheses, in-
These results go on to suggest that socket design. This may indicate that structional training, and local athletic
middle-aged amputees may find rec- improved socket design is having a organizations that permit them to
reational activities intimidating, but positive effect on the superficial shear compete or participate on an equal
that they acquire a degree of comfort force at the limb-socket interface. 8 •9 footing. In fact, the suggestions from
through instruction and working with Support and motivation are obvi- the amputees to improve functional
others in groups. Older amputees, ously key ingredients for getting peo- activity included better prostheses
however, may be more willing to re- ple involved in leisure activities. Sixty (60%), amputee instructors (35%),
turn to prior activities independently, percent of the amputees reported that instructional literature (24%), and
with less fear of embarrassment.8 •9 family and friends were encouraging additional supportive sports organi-
One common problem for all am- about their activity level. Unfortu- zations (18%).8 ' 9
putees, especially the elderly, is diffi- nately, when participants were asked
culty with their prosthesis during how informative members of the
physical activity. Thirty-seven percent medical profession were about recre-
Running
of amputees experience prosthetic ational activities, the results were dis- Although running is a lower ranked
problems all of the time during activ- appointing. Only 6% of physicians activity, amputees list the inability to
ity. As amputees age, this pe'rcentage were perceived by the respondents to run well as the single most common

a prosthesis is not as intuitive as run- strikes the ground, a backward force is

ning with the anatomic limb. It generated by the strong contraction of
therefore becomes important for cli- the hip extensor muscles while the hip
nicians and coaches as well as ampu- abductors provide the necessary pel-
tee athletes to become familiar with vic stability. 19 Muscular stabilization
the biomechanics of running for coupled with joint motion, creates ~
able-bodied runners as well as for biomechanical spring that reduces
amputee runners. the effects of the ground- reaction
Running is most often described in forces.20•21
terms of speed, but the skills are When amputees run, there is no
much more complex. Because de- peak in ground-reaction force for the
scribing every type of rwrning would prosthetic limb. This reduction in
be too comprehensive for this text, ground-reaction force suggests that
the focus will be on the skills for the amputees both absorb and generate
novice amputee runner and present less energy with their prosthesis than
Figure 1 Transtibial amputee in the ab- some insight into the techniques used do runners with intact limbs. The re-
sorption phase of running. (Copyright © by accomplished amputee runners. duction in energy generated by the
Advanced Rehabilitation Therapy, Inc, Mi- prosthetic limb could be the result of
ami, FL, 2002. Illustrator Frank Angulo.)
a more passive use of the limb, the ab-
Biomechanics of
sorption of forces by the soft tissue
factor limiting participation in recre- Running encapsulated within the socket, or the
ational activities; it is their most de- The running cycle is divided into presence of an isometric or stabilizing
sired skill. That running is a prerequi- stance and swing phases. During contraction by the muscles.22
site skill for sports is a misconception, stance phase, the period from initial As the transtibial amputee strikes
however. Most sports either require contact to midstance is referred to as the ground with the prosthetic limb, a
very little running or can be partici- the absorption phase, when the body backward force is instantly created by
pated in if some minor adaptation is decelerates as the runner contacts the the prosthetic side hip musculature.
made. Many amputees who do not ground. From midstance to toe-off is This generates two to three times
have a strong desire to run for sport known as the acceleration or propul- more work than the contralateral
or leisure may have an interest in sion phase, when the body's accelera- limb, partly to help move the body
learning how to run simply for the over the stationary foot as well as to
peace of mind that comes with the
tion carries over to initial swing as the
limb enters the swing phase. From
•
compensate for the loss of active •
knowledge that they can move quickly midswing to terminal swing, the limb plantar flexion at the ankle. 23•24
to avoid a threatening situation. 14 begins to decelerate as it returns to One notable difference between
Rarely, if ever, is running taught in re- the absorption phase. The beginning novice and well-trained transtibial
habilitation. Running, as with all gait and end of each swing phase has a pe- amputee runners is that novice run-
training and advanced skills, takes riod of double-float, when neither ners have a reduction in knee flexion
time and practice to master. Ampu- limb is in contact with the ground during the absorption phase. With
tees should be exposed to basic run- while the body is moving through proper training, strength, and ade-
ning skills during rehabilitation so space. As a result, the stance phase ac- quate residual limb length, knee flex-
that they can pursue running if they counts for less than 50% of the run- ion comparable to that with an intact
wish. ning gait cycle. As speed increases, the limb can be achieved with the pros-
Learning to run is not an easy task percentage of the cycle represented by thetic Limb.
for the lower limb amputee, whether the stance phase decreases, becoming The length of the residual limb
or not the person is athletically in- as little as 20% in sprinters. 15- 17 and the amount of muscle mass re-
clined. Most nonamputee runners in- tained play important roles in deter-
tuitively link running mechanics and Absorption Phase mining the transfemoraJ amputee's
the economy of running. As a result From initial contact to midstance is re- running potential. This has become
of training, most nonamputee run- garded as the absorption phase (Figure most apparent in recent years as knee
ners are able to adopt a rwrning style 1), when t he lower limb acts as a shock disarticulation amputee runners have
that is most economical for their own absorber for the body, thereby reduc- become extremely successful in com-
personal n eeds. The amputee runner, ing the considerable ground-reaction petition. The additional power poten-
however, is at a disadvantage when forces passing upward through the tially available to knee disarticulation
attempting to develop an efficient limb, which can be two to three times runners should not overshadow the
running style because learning to use greater than body weight. 18 As the foot need for athletic ability and training.

Acceleration Phase
from midstance to terminal stance
and through initial swing is referred
to as the acceleration phase of the
running cycle (Figure 2), when the
body moves from stance phase energy
absorption to acceleration or genera-
tion of speed. At this point, most of
the forward propulsion of the body
comes from the contralateral swing
limb and the arms.
The well-trained transtibial ampu-
tee can achieve flexion -extension pat-
terns similar to those of nonamputee
runners during stance. Contracting of
the quadriceps and the calf muscles Figure 2 Transtibial amputee in the ac- Figure 3 Transtibial amputee in the de-
celeration phase of running. (Copyright celeration phase of running. (Copyright
creates adequate knee stability. Many © Advanced Rehabilitation Therapy, Inc,
© Advanced Rehabilitation Therapy, Inc,
believe that the J-shaped design of the Miami, FL, 2002. Illustrator Frank An- Miami, FL, 2002. Illustrator Frank An-
flex-Foot (Ossur, Aliso Viejo, CA) 1 gulo.) gulo.)
which permits controlled dorsiflex-
ion, assists significantly with control
varying degrees in prosthetic feet. Dy- cal work of the hip, or the energy gen-
of knee flexion. In fact, the Flex-Foc,t
namic feet have been found to gener- erated by the intact hip flexo rs, was
has been found to provide a more
ate two to three times more elastic en- found to be more than twice the mag-
normal pattern of muscle activity in
ergy than a solid ankle-cushion heel nitude of that generated in nonampu-
the hip and knee extensors through-
out the stance phase.25 (SACH) foot. 22 In 1991, Czerniecki tee runners, with the work of the hip
The transfemoral amputee's hip and associates 22 defined spring effi- on th e prosthetic side being some-
remains in a neutral position and is ciency as the amount of energy gener- what greater than normal but not as
related to the extended prosthetic ated divided by the amount of energy great as on the intact side.23
knee. To continue advancement over absorbed. The spring efficiency of the
SACH foot was found to be 31 %, Deceleration Phase
the prosthetic stance limb, the ham-
strings and gluteus maximus promote whereas that of the Seattle foot (Seat- In the deceleration phase (Figure 3),
rapid hip extension. 25 The amount tle Systems, Inc, Poulsbo, WA) was as the foot prepares to strike the
of ankle dorsiflexion present is a di- 52% and that of the Flex-Foot was an ground, the thigh muscles are prepar-
rect result of prosthetic foot design impressive 82%. In comparison, the ing to propel the body forward while
and alignment. To date, the Flex- human foot has 241 % spring effi- also absorbing the ground-reactive
Sprint (Ossur, Aliso Viejo, CA) design ciency because of the additional con- forces . The hip extensors work eccen-
has delivered the maximum rnecl1an- centric plantar flexion contraction of trically to decelerate the thigh and leg
ical energy return for transfemoral the triceps surae. during late swing and extend the hip
runners. At terminal stance, the transtibial prior to, and immediately upon, ini-
As the hip reaches maximum ex- amputee runner's total muscle work tial contact. The hip abductors and
tension, all movements are passive on the prosthetic side is half that adductors contract to stabilize the
during terminal stance except for measured in the intact limb and in pelvis as the foot approaches initial
those of the hip adductors, which nonamputee runners. This is not too contact.20
contract to stabilize the pelvis. The surprising, considering that the plan- Transtibial amputee ru1mers tend
peak plantar flexion is the result of tar flexors are absent. To compensate, to have lower angular velocities at
the rapid movement of the tibia over the amputee's intact swing-phase leg peak flexion and extension as well as
the foot, creating a rigid lever in the increases energy transfer by about maximal hip and knee flexion angles.
foot to release the elastic energy. Dur- 75%.27 In addition, premature extension of
ing nonarnputee running, more than Hip :flexion is initiated by a power- the knee during swing is commonly
half the elastic energy is stored in two ful contraction of the hip flexors. Sta- observed. Socket designs, coupled
springs, the Achilles tendon and the bility with a steady line of progression with suspension requirements, have
arch of the foot. 26 of the limb is maintained by stabiliz- been identified as probable causes for
The elastic energy found in the an- ing contractions of the hip abductor the reduction in peak knee flexion,
atomic foot has been replicated to and adductor muscles. The mechani- which, in turn, limits hip flexion .25

Creating a transtibial socket that probe flexed when moving toward exten- third law) . The result is that each time
vides both stance-phase stability and sion, the knee should be flexed, and the foot contacts the ground, forward T,
swing-phase mobility has been a diffi- the prosthetic foot should be momentum is decreased. In other s·
cult task. dorsiflexed. Knee flexion not only per- words, with every stride, the amputee Pi
The transtibial amputee contracts mits greater shock absorption but also is slowing down when running with T
the muscles of the lower Limb in a creates a backward force between the ilie hop-skip gait. p
pattern identical to tJ1e nonamputee ground and the foot to provide addi- Most transfemoral amputees a
fc
during terminal swing. The knee tional forward momentum. (2) As the achieve the abi[jty to run leg-over-leg re
should be slightly flexed, and, as center of gravity is transferred over the through training and working with s
stated earlier, there will be a reduction prosthesis during stance phase, the ip- knowledgeable coaches. The transfem- B
in forces as the foot prepares to strike silateral arm should be fully forward oral amputee takes a full stride with T
the ground.23 . (shoulder flexed 60° to 90°) while the the prosthetic leg, followed by a typi- Ii
The transfemoral amputee must contralateral arm is back (shoulder ex- cally shorter stride with the sound leg. b
tended) . Extreme arm movement can a
land with the prosthetic knee ex- With training, equal stride length and f,
tended. Initiating a backward force be difficult for the amputee concerned stance time may be achieved. This c
before initial contact will not only ac- with maintaining balance. (3) During f
running pattern is a more natural gait
celerate the body forward but also en- the acceleration phase, the hip should in which the double support phase of
sure that the knee remains in exten- be forcefully driving down and back the sound limb is e[jmjn ated and for-
sion. Although it is unnecessary, through the prosthesis as the knee ex- ward momentum may be maintained
many transfemoral amputee runners tends. If the prosthetic foot has dy- by both legs. Initially, other problems
also adopt an extended trunk posture namic elastic response, the force that may occur include excessive
as the prosthetic foot prepares to produced by hip extension should vaulting off the sound limb to ensure
strike the ground. deflect the keel so that the pros- ground clearance of the prosthetic
thetic foot provides additional push- limb, decreased pelvic and trunk rota-
off. (4) During the forward swing and tion, decreased and asymmetric arm
Trunk and Arm Swing
float phase, the hip should be rapidly swing, and excessive trunk extension.
For amputees, symmetry of arm flexing, elevating the thigh. The arms
movement is extremely important, yet Again, with training, many of these
should again be opposing the advanc- deviations will decrease and possibly
often difficult to master. They must ing lower limb, with the ipsilateral arm
make a concentrated effort to restore a be eliminated.
backward and the contralateral arm
symmetric arm swing, especially as The leg-over-leg running style does
forward. (5) During the late decelera-
speed increases, when the legs have a permit the transfemoral amputee to
tion phase or foot descent, the hip
tendency to lose symmetry of move- rtin faster for short distances but at a
should be flexed and beginning to ex-
ment. greater metabolic cost. Although leg-
tend as the knee is rapidly extending
Transfemoral amputees have a ten- over-leg is preferred, the hop-skip
and reaching forward for a full stride.
dency to increase abduction of the method is often more easily taught
Traditionally, transfemoral ampu-
prosthetic side arm, especially when and is less demanding physically.
tees and individuals with knee disar-
the prosthetic lower limb is abducted. When the sole purpose of running in-
ticulations run with a period of double
The adverse positions of both the leg struction is to teach tJ1e individual to
support on the sound limb during the
and the arm create opposing forces move quickly in a safe and sure man-
running cycle, commonly referred to
that tend to impede forward momen- ner, the hop-skip meiliod is most fre-
as the hop-skip running gait. The typ-
tum and increase the metabolic re- quently suggested.
ical running gait cycle begins with a
quirement. Likewise, poor medial/ long stride with the prosthetic leg, fol-
lateral socket stability will require lowed by a shorter stride with the The Five Basic Steps
additional effort by the prosthetic-side sound leg. To give the prosthetic leg
arm and facilitate unwanted trunk
of Amputee Running
sufficient time to advance, the sound
movement. leg takes a small hop as the prosthetic Learning how to run using a prosthesis
limb clears the ground and moves for- can be very challenging, yet when sim-
ward to complete the stride. The speed p[jfied into a series of basic elements it
Running Skills that a transfemoral amputee can can be much easier to learn. Table 2
Individuals with Syme ankle disarticu- achieve will be limited because every describes the five basic steps that have
lations and transtibial amputees can time either foot makes contact with made it possible for hundreds of am-
achieve the same running biomechan- the ground, the forces of the foot are putees with all levels of amputation to
ics as able-bodied runners if they em- traveling forward, and the reaction relearn the skill of running and have
phasize the following: (1) At ground force of the ground must be in a back- enabled iliem to benefit from the abil-
contact the prosthetic limb hip should ward or opposite direction (Newton's ity to move rapidly when necessary.

Ch apter 51: Physical Therapy for Sports and Recreation 647
and knees designed for running can

TABLE 2 The Five Basic Steps of Amputee Running reduce effort and improve perfor-
mance.
Step 1
prosthetic Trust
The ru nner must first gain trust in the prosthesis and develop confidence t hat the
prosthetic limb will be there and will not collapse when it strikes the ground. This is
Prostheses for
accomplished by reaching out with the prosthetic limb and landing squarely on the Ath letics
1
foot. The runner is taught to ignore everything else, knowing that the prosthetic limb is
reliab le.
Prosthetic Components for
Step 2 Sport s
Backward Extension The prosthetic options for recreational
The runner reaches out with the prosthetic foot during swing. Just as t he prosthetic and competitive athletes have grown
limb strikes the ground, the runner pulls the prosthetic leg back forcefu lly, creating a
backward force which propels the run ner forward. The ground also produces a forward
tremendously through the years. Un-
accelerating force on the body. This movement has two effects: First, it propels the body fortunately, the literature offers very
forward w ith increased speed. Second, it produces t he power to shift the body's weight little insight into the ftmctional differ-
over the prosthesis and fully load the prosthetic foot, resulting in maximum prosthetic
foot performance as the forefoot is loaded
ences between appliances and the im-
pact that they have on performance.
Step 3
Part of the process of training is learn-
Sound Limb Stride
The focus shifts to the sound limb. The runner concentrates on taking a longer stride
ing how to maximize the use of pros-
with the sound limb, easily accomplished by continuing t o pull down and back through thetic components. In particular, pros-
the prosthetic limb. Pulling back during the prosthetic foot's initial contact with the thetic knees and feet can be
ground initiates the movement pattern. The runner continues to extend the hip by
pulling down and back into the socket. This generates more power and a stronger
tremendous assets to an athlete but,
push-off with the prosthetic limb, which enables the sound limb to reach out to unfortunately, their influence is often
complete a ful l stride. overlooked. Once a foundation of
Step4 strength and endurance is established
Stride Symmetry and use of a prosthesis is understood, a
This phase is designed to decrease the enormous effort being exerted, and to simply training program to improve or main-
relax and jog a little. The runner chooses a comfortable jogging pace that produces an
equal stride for both limbs. There is no concern for the arms. Attention is focused on
tain athletic performance should be
maintaining stability over the prosthetic limb using the muscles of the hips to create designed to meet the specific needs of
equal and relaxed strides. each athlete.
Step 5
Arm Carriage Socket Design and
The runner focuses on arm swing. The arms and legs move in opposition to each other Suspension Systems
during gait, so as the right leg moves forward, so will the left arm. The elbows should
flex to about 90° and the hands should be loosely closed and rise to j ust below chin The use of secondary suspension sys-
level when brought forward. Just as in walking, arm swing is the result of trunk rotation tems is common among athletes. Suc-
as the trunk and pelvis rotate in opposition to each other for balance, momentum, and tion is the primary suspension system
economy of effort.
used today. Suction suspension can be
created through a variety of compo-
Adapted with permission from Gailey RS: The Essentials of Lower Limb Amputee
Running and Sports Training. Miami, FL, Advanced Rehabilitation Therapy, Inc, 2004. nents including pull-in suction sock-
ets, internal roll-on locking liners,
and one-way suction valves. No spe-
cific method of suspension has been
Initially, for safety reasons, it is climbing. In time, runners will de-
shown to be superior, so this remains
strongly suggested that amputees work velop their own comfortable running
a clinical decision while materials and
with skilled clinicians and use a gait style, depending on the sports or rec-
fitting techniques continue to evolve.
belt to soften the impact of a fall. reational activities chosen . Socket design and suspension
After mastering the five basic steps Running can be learned on just choice are frequently determined
of running, amputees should be ready about any type of prosthesis. Initially, through trial and error until a com-
to put all the individual elements of the type of prosthetic foot is not crit- fortable fit is achieved. Generally
running together. They should relax ical. However, if amputees decide that speaking, most recreational athletes
and think about only a couple of ele- running is going to be a part of their will find that the socket design used
ments of running with each pass. lifestyle, they should discuss the avail- for their walking prosthesis will serve
Many long distance runners augment able options with their prosthetist. them well for most sports. It certainly
their endurance training program The same principles of running apply, is appropriate to use the walking
with low-impact activities, such as regardless of the prosthetic foot and prosthesis as a starting point when
swimming, stationary biking; or stair knee systems; however, prosthetic feet designing an athletic prosthesis. After

for only a short period of time and trol. The other alternative is a total
is not very comfortable. Fortw1ately, elastic suspension (TES) belt, which
roll-on suspension sleeves and better can be used as needed because it sim-
suction have dramatically reduced ply slips over the socket and around
the need for such a tight fit for most the waist. The TES belt tends to be
athletes. warmer and a little more restrictive
Socket design should also include than the Silesian belt, but it can be re-
consideration of volume changes over moved.
time. Long-distance rum1ers, depend-
ing on the individual, may experience Socket Stability
residual limb swelling, loss of volume, Stability in the socket may be estab-
or very little volume change. Stopping lished surgically with combined
to add socks or change liners during a myoplasty/myodesis procedures that
race may not be feasible; therefore, stabilize the muscles by suturing mus-
experimenting with socket size and cle to muscle and muscle to bone. In
liner materials may be necessary. Sec- addition to creating anatomic stabil-
ondary suspension systems can aug- ity, some prosthetic socket designs
ment socket designs by preventing not only create stability but also help
excessive pistoning and controlling maintain normal bony alignment,
unwanted movement that could result thereby placing the residual m uscles
Figure 4 A t ranstibial athlete who has in-
when volume changes occur. in a functionally tensioned position
corporated a rig id knee orthosis into a The type of secondary suspension so they can provide maximal contrac-
prosthesis to protect against excessive selected is often unique to each ath- tion to aid prosthetic control in ev-
medial/lateral or rot ation motion. (Cour· lete. As a rule, most athletes prefer to eryday activities. Although the bene-
tesy of Advanced Rehabilitation Therapy, wear as few additions as possible be- fits of surgical procedures and socket
Inc, M iami, FL.)
cause of weight and restriction of designs are frequently debated, most
movement. External suspension authorities agree that anatomically
the athlete participates in the chosen sleeves have become very common for sound surgery and a well-designed
sport, modifications may be made ac- transtibial amputee athletes because socket will be of some advantage to
cording to comfort and performance. they assist with suction suspension. the amputee. Nonetheless, unless the
For example, transfemoral amputees They can be excessively warm, how- amputee learns to use the muscles ef-
who are recreational cyclists charac- ever, increasing perspiration within f~tively within the socket, there will
teristically prefer to have the proximal the socket as well as restricting knee be no benefit from advances in sur-
brim trimmed down, especially medi· flexion as the material bunches in the gery and socket design.
ally, to reduce rubbing along the popliteal area. Supracondylar cuffs are Stability within the socket is essen-
groin. They require little additional still worn by many athletes as a light- tial to quality performance. Stability
suspension, as losing the prosthesis is weight secondary suspension, but requires not only strength but also the
not likely because they are in constant these cuffs can also feel somewhat re· ability to control movement in all di-
contact with the foot pedal. Likewise, strictive. Occasionally, transtibial am- rections and at varying speeds. Learn·
transtibial amputee cyclists reduce the putees wear waist belts with inverted ing to use the remaining muscles
brim and use a minimum of suspen- Y-straps more for psychological secu· witl1in the socket in a way that allows
sion to permit maximal knee flexion. rity than actual suspension. Transtib- control of forces placed on the pros-
Transfemoral amputees who are com- ial amputee athletes who have knee thesis from any direction will assist
petitive cyclists do not wear a pros- instability may want to add a rigid tremendously in all activities requir·
thesis during races because, if a pros- knee orthosis to protect against exces- ing speed, power, and agility. A train-
thesis is used, they would have to sive medial/lateral or rotation motion ing program designed to improve sta-
compete against transtibial amputee (Figure 4). Rigid knee orthoses have bility within the socket should focus
cyclists. replaced the thigh corset with metal on joint proprioception, where the
Other sports may require an ex- uprights in m ost cases because of the speed of contraction, not the maxi-
tremely tight fit for prostheses. For reduced weight, stronger material, mal force of the contraction, becomes
instance, some ~ompetitive sprinters improved ventilation, ease of don- the emphasis of the exercises.
choose a socket design that is ex- ning, and increased freedom for mus- The following exercises are de·
tremely tight to prevent unnecessary cle contraction. signed to build strength and power in
motion within the socket and reduce Transfemoral amputee athletes wiJl multiple directions in a low-impact
the need for secondary suspension. typically use a flexible Silesian belt to fashion, thereby reducing the stress
This type of prosthesis can be worn aid in suspension and rotational con- on the residual limb and the chance

Chapter 51: Physical T herapy for Sports and Recreation 649
Figure 5 Lateral agility drill. (Copyright© Advanced Rehabilitation Therapy, Inc, Miami, FL, 1989. Illustrator Frank Angulo.)
•
of injury. The exercises can improve Exercises for to maintain stability. As skill level im-
the overall abilities of amputees of proves, braiding or placing one leg in
Maximizing Stability front of the other and then behind on
any functional level and allow tl,em
to get the most benefit from their sur- Within the Socket the subsequent step will help the ath-
gical procedure and socket design. lete develop the speed of residual
Lateral Agility Drills limb movement and stability neces-
Lateral agility drills28 are one of the sary to move confidently in any direc-
strategies necessary for moving in dif- tion. To improve dynamic balance,
ferent directions. The amputee simply the athlete should perform braiding
moves sideways for a predetermined with trunk rotation in which the
distance, starting witl1 slow steps and trunk moves in opposition to pelvic
picking up speed as the movement motion. As agility improves, the ath-
becomes easier. Athletes who partici- lete can vary the speed during the lat-
pate in sports that require lateral eral agility drills to approximate game
movements regularly, such as tennis, conditions and further improve pros-
basketball, and softball, should prac- thetic control in multiple directions.
tice at speeds consistent with their
sport. Once speed and balance have
Cup Walking Drills
been established, the drills can in-
clude the use of a racquet or ball, add- A cup walking drill 28 is a challenging,
ing more complex skills such as low-impact exercise that has been
swinging the racquet or passing the shown to be extremely beneficial in
ball during each repetition. helping amputees learn to control
Crossing one leg in front of the their prosthesis. Five to 10 disposable
other also assists in learning move- cups should be placed in a row ap-
ment strategies in multiple directions proximately 12 to 18 in apart. Paper
(Figure 5) . Care must be taken not to cups .are a good choice because they
bump the prosthetic knee with the crush more easily than plastic if
sow,d limb, which can cause tl,e stepped on (Figure 6). Starting at one
Figure 6 Cup walking drill. (Copyright end of the row of cups, the athlete
prosthetic knee to collapse. Rapidly
© Advanced Rehabilitation Therapy, Inc,
creating a backward force within tl,e slowly raises one leg while stepping
Miami, FL, 2002. Illustrator Frank An-
gulo.) socket witl1 hip musculature will help forward so that tl,e knee is waist high,
American .Academy of Orthopaedic Surgeons

or so that a 90° angle is formed at the Sports and Prosthetic might develop an interest. Not all
hip, and then slowly returns the foot sports require ultradynamic pros-
to the floor while stepping over the
Ankle/Foot Options thetic feet. In fact, many amputees P•
cup. Using the alternate leg, the pro- The choice of prosthetic feet for participate in sports such as golf, la
cedure is repeated over the next cup. sports remains a clinical decision, and bowling, sh uffleboard, and boating, n•
When balancing over the pros- there are very few sports-specific which require more mobility than dy- st
thetic limb as the sound limb ad- prosthetic feet. The most popular namics. s~
vances, the athlete should focus on sports feet are designed primarily for Mu1tiaxia1 foot systems with dy- CC
three key elements: First, for the running. Fortunately, most sports do namic keels provide the advantages of n:
transfemoral amputee, only the mus- not require extensive running, so an a moveable ankle, whereas the elastic rr.
cles within the socket, the buttocks, everyday prostl1esis with appropriate keel offers the benefits of a dynamic- pl
and the thigh muscles on the pros- components and suspension may al- response foot. Because of the mobility h:
thetic side are contracted. The trans- low recreational amputee athletes to at the ankle, it is believed that some of d:
participate. Some people who are the "energy release" generated in
tibial amputee should also contract IT.
comfortable with their socket and/or dynamic-response feet with moveable fc
the buttocks and thigh muscles in ad-
knee system will elect to change just ankles is not as great. But a multiaxial it
dition to those within the socket. Sec-
their prosthetic foot for certain foot/ankle system should be strongly LL
ond, a downward force through the
sports. A small adapter can be pre- considered for persons who walk on ir
socket creates maximal weight bear- scribed to provide athletes with a hills or uneven terrain, such as golf- w
ing within the socket. Third, the quick-changing, self-aligning device ers, or those who need movement in 0
weight of the body must pass over the to permit amputees to quickly swap all planes of motion, such as bowlers ti
prosthetic foot to maintain weight prosthetic feet or knee-shin systems. and shuffieboarders, or those who re- ai
over the great toe of the prosthetic Competitive athletes may have a quire motion at the ankle for standing 0
foot. sport-specific prosthesis, particularly balance, such as boaters. II
One of the major benefits of this for high-impact activities that acceler- The source and the degree of mo- f(
exercise is the heightened awareness ate wear and tear on the components. bility available in prosthetic feet have Ii
of the prosthetic foot. Feeling the When selecting a prosthetic ankle/ changed tremendously through the ti
body weight over the foot and learn- foot system, it is important to discuss years. No longer does motion come d
ing how to balance over the foot will recreational and sports interests thor- only from the ankle, although multi- ~
enhance prosthetic control in a vari- oughly because amputees will likely axial ankles are still very popular. n
ety of activities. try to participate in their favorite Other options include the "split- iJ
A number of variations can be in- sport in the first year after amputa- t<.e"- a divide running the length of b
troduced into the cup drill. For in- tion. If the prosthetic components do the foot plate-permitting motions SI
stance, walking on a compliant or not respond to the demands of the that replicate ankle inversion and n
foam surface increases the need for sport, chances of success will dimin- eversion without absorbing as much a
stability within the socket of the pros- ish, resulting in frustration and em- elastic energy as rubber bumpers in
thetic limb to execute the exercise ex- barrassment that may keep the person an ankle joint. The advantage is mo- tJ
actly the way it is performed on a solid from ever participating in that sport tion without much loss of dynamic p
floor. The athlete needs to maintain again. Many prosthetic feet are suit- properties. Another design that has
knee stability in all directions and
able for walking but are not dynamic become very popular uses elastomer "a
enough for sport. As a result, when or other types of hard rubber sand- a
therefore must react faster with the
higher loads are placed on the foot, wiched between primary and second- i:
muscles of the knee and hip to main-
the energy is absorbed without any ary foot plates. Once again, frontal
tain balance. Sideways walking will
energy release, resulting in perfor- plane and some transverse plane an-
further challenge the residual limb
mance unacceptable to the amputee. kle motion can be mimicked while
musculature and improve balance.
Therefore, it is very important to pre- maintaining foot dynamics. Other
Backward walking is another skill scribe a foot that not only permits a foot designs incorporate shock ab-
that helps develop prosthetic control. natural gait but also allows the ampu- sorbers and rotators in the shin above
Athletes should focus on the same key tee to participate in recreational the traditional ankle location, provid-
elements: contracting the muscles, ex- sports. In other words, components ing long-axis rotation. These shock
erting a down_ward and backward should be prescribed that are suitable absorbers and rotators can be coupled
force within the socket, and feeling for the highest level of activity antici- with any number of foot designs.
the weight progress over the pros- pated by the amputee. The degree of motion required
thetic foot. Limiting any unnecessary During the initial evaluation, the should be determined by the everyday
movement from the trunk will also prosthetist should explore the recre- environment that an amputee must
help. ational sports in which the amputee negotiate and the recreational activi-

ties in which he or she chooses to par-

A
ticipate. A golfer who lives in a hilly
part of the cou ntry will need a fairly
large degree of motion in all planes to
negotiate hills when walking, adopt a
stance on uneven terrain, or permit
some rotation during the swing. In
contrast, a bowler may require a sig-
nificant degree of sagittal plane
movement, with dorsiflexion and
plantar flexion, but may not want to
have much frontal plane motion. A
dynamic-response prosthetic foot
meeting these guidelines would allow
for a rapid approach, whereas the sag-
ittal flexibility would permit the req-
uisite lower Limb motion as the bowl-
ing ball is released. Boaters, however,
want to keep the prosthetic foot flat
on the deck of the boat and would
therefore prefer some motion at the Figure 7 ':'· Cheetah running foot. (Courtesy of Ossur, Aliso Viejo, CA.) B, Transtibial am-
putee sprinter competing with a Cheetah running foot.
ankle to adapt to the rocking motion
of the boat. If the prosthetic ankl;
moves slightly to accommodate the putee athletes to run almost as fast as ing conditions. The forces generated
rocking motion, similar to the sound able-bodied Olympic medalists. during sprinting cannot be recreated
limb's motion, the muscular effort at in the office or parking lot. Using a
the proximal joints will be reduced, video camera to film the athlete at
Cheetah
decreasing tl1e fatigue of sta nding competitive speeds from multiple an-
while on the boat. Too much motion Designed primarily for unilateral and
bilateral transtibial amputees, Cheetah gles and then reviewing the footage at
may have an opposite effect and result slow speeds is ilie only effective
in greater muscu lar effort to control foot components (Ossur, Aliso Viejo,
CA) are inherently plantar flexed to method to align a running prosthesis.
balance on the prosthetic foot, so the Trimming the distal end of the foot
stiffness of the motion-limiting ele- keep sprinters on ilieir toes. The distal
posterior pylon is bowed, lengthening plate should be done only to reduce
ments must be individualized for each the sharp edges. The longer the foot
amputee. the foot plate to increase ilie moment
arm for maximal deflection so that, as plate, the longer tl1e stance phase, giv-
There are far too many variables to
the material energy is returned, it will ing the sound limb time to achieve full
try to match a sport with a particular
propel the athlete's limb into ilie accel- hip flexion. This of course may be in-
prosthetic foot. Suffice it to say that a
eration phase of swing (Figure 7). Be- dividual to each athlete, but any re-
wide variety of dynamic feet is avail-
cause of the forces applied to the foot duction in length should be done only
able today to meet almost everyone's
during sprinting, the height of the after the athlete has achieved final
activity level. What is most important
prosthetic limb is typically 1 to 2 in alignment or feels that the lengili is a
is that the amputee's recreational in-
higher than the sound limb, allowing consistent hindrance. Otto Bock
terests be explored at the time of
for ilie decreased height when the foot HealthCare (Minneapolis, MN) ma11 -
prosthetic prescription and an appro-
is compressed. The goal is to have the ufactures ilie Sprinter foot, which has
priate choice be made.
pelvis level during midstance and to a similar design to the Cheetah.
eliminate any unnecessary trunk or
Prosthetic Sprinting Foot head movement. Spring stiffness also Flex-Sprint
Options plays a significant role in foot com- The Flex-Sprint (Ossur), an inverted
Sprinting feet are designed, selected, pression. A number of athletes believe }-shaped prosthetic foot, is popular
and aligned to maximize sport perfor- that they perform better when the foot with transfemoral amputee sprinters.
mance but are neither safe nor effec- is not too stiff. There is no posterior bow, which
ti~e for normal walking. When com- The manufacturer provides the ini- moves ilie ground-reaction force an-
brned with a sprinting-specific socket tial alignment setup for the running teriorly, making the prosthetic knee a
~nd suspensions, these specialized foot, but individual alignment changes little more stable. An optional heel
hmbs have enabled well-trai"ned am- must be made at the track under train- module is avai lable for transtibial am-

foot and the knee moments, where le

there is just enough stability to ensure d
that the knee will not buckle but not b
so much that knee flexion becomes tl
difficult (Figure 8) . fc
Sprinting feet typically provide no d
medial/lateral mobility, so all motion b
occurs only in the sagittal plane. Al- cl
though novice runners do not need
these specialized feet to start training,
no elite track athletes have competed r
over the past decade without using J
these specialized designs.
I
C-Sprint 1
C-Sprint feet (Ossur) are designed for i:
long-distance running or jogging. Be- 1,
cause of the exaggerated posterior bow c
shape, its vertical compliance is much s
greater than in any other running foot (
design (Figure 9). C-Sprint feet have f

been used successfully by transtibial
amputees, transfemoral amputees, and
Figure 8 A, Flex-Sprint runn ing foot. (Courtesy of Ossu,; Aliso Viejo, CA.) B, Transfemora l bilateral amputees who want to run
sprinter competing with a Flex-Sprint foot.
longer distances. To take full advan-
tage of this design, the athlete lands on
the prosthetic toe, extending the hip
A
throughout the support phase and
achieving maximal deflection of the
foot. As the prosthetic limb is about to
enter the acceleration or swing phase,
tLie effort for jogging is minimized by
allowing the foot to initiate the up-
ward motion. Then, as the spring ef-
fect reaches a peak, upward accelera-
tion is continued by flexing the hip as
the limb moves into the float phase.
Runners perceive less muscular effort
after they gain a sense of the foot's
compression and release, allowing the
foot to initiate upward momentum
while they use the hip flexors to con·
tinue the forward progression of the
limb. There is no evidence to support
claims of reduced work while running
with C-Sprint feet. Nevertheless, the
"bouncy" sensation that amputee run-
ners experience with a little traini~g
Figure 9 A, (-Sprint runn ing foot. (Courtesy of Ossu,; Aliso Viejo, CA.) B, Transfemoral seems to result in a more rhytbnuc
distance runner competing w ith a (-Sprint foot designed for long-distance running or running pattern. This may increase the
jogging.
chance that they can reach a steady
putees wearing ·this style of foot who to bounce off the prosthetic foot and state. The benefit of being able to es-
want the security of knowing they have a marked reduction in hip flex- tablish a comfortable pace is that the
will not hyperextend the knee if their ion with both · the prosthetic and amputee runner can then develop
weight falls posterior to the shin. sound limb. An alignment balance muscular and cardiopulmonary en-
Transfemoral amputee sprinters tend must be made between the prosthetic durance using the prosthesis while al-

Chapter 51: Physical Th erapy for Sports and Recreation 653
lowing the residual limb to gradually

develop a tolerance to the high forces
being applied within tl1e socket. Al-
though few amputees choose to run
for long distances as a method of en-
durance training, this option is possi-
ble for many individuals, particularly
those with unilateral limb loss.
Maximizing
Ankle/Foot
Performance
The functional ability of the amputee
is the primary consideration when se-
lecting the appropriate foot/ankle
components. A rehabilitation plan de-
signed to match the specific require-
ments of the prosthetic co1nponents =
fitted will optimize the effectiveness
of the prescription. Matching the
right exercises to the ankle/foot a!--
sembly permits optimal use of the Figure 10 Toe-box jumps. (Copyright Figure 11 Lateral speed weave. (Copyright
prosthesis and improves athletic per- © Advanced Rehabilitation Therapy, Inc, © Advanced Rehabilitation Therapy, Inc,
Miami, FL, 2002. Illustrator Frank An- Miami, FL, 2002. Illustrator Frank Angulo.)
formance.
gulo.)
Dynamic-response prosthetic feet
can allow the amputee to run faster
with greater ease and agility. They are feet together, then jt1rnps diagonally to speed, power, and agility in all direc-
typically designed for amputees who the opposite mark, landing on the toe tions by having t he amputee run for-
have the ability to vary their walking of the prosthetic foot and using the ward to the side, backward to the side,
speed or change directions quickly, or unaffected limb for balance. The body and forward again.
who want to run. The advantages of weight loads the prosthetic foot; then, Because of the differences in knee
dynamic-response feet are realized as the deflector plate releases its stored control, the transtibial amputee and
only if the transition of weight over energy, the athlete quickly pushes off, transfemoral amputee should per-
the foot is of the magnitude and du- using the quadriceps muscle to extend form this exercise slightly differently.
ration to permit the deflector system When transtibial amputees run in and
the knee to the next mark to the lateral
to work as designed. In other words, out of the cones, they should empha-
side. Again landing on the toe of the
to take full advantage of a dynamic- size staying on the toe of the pros-
prosthetic limb and balancing with the
response foot, full body weight must thetic foot for quick acceleration and
unaffected limb, the athlete jumps di-
pass over the foot long enough for the deceleration. Again, it is in1portant to
deflector plate to bend fully and store agonally to the last remaining mark. focus on the time between the deflec-
the energy and then allow the elastic Initially, a spotter should be present tion of the prosthetic foot plate and
properties to release the stored en- for safety. Timing of foot release and extension of the knee to achieve max-
ergy. Athletes should spend time knee extension is the focus of this ex- imal power. This exercise prepares the
learning how to properly land, load, ercise, as well as learning how to take athlete for multidirectional move-
and change direction with the pros- advantage of the prosthetic foot's en- ments that include starting, stopping,
thetic foot in order to maximize ath- ergy return (Figure 10). and changing direction. Trans-
letic performance. femoral amputees should concentrate
Lateral Speed Weave on learning to control the flexion and
Exercises to M aximize For the lateral speed weave,28 four to extension of the prosthetic knee. As
Performance five cones are placed approximately the prosthetic lin1b moves forward, a
Toe-Box Jumps every 4 ft with another alternating set full-length step is achieved as the
For toe-box jumps,28 four pieces of of cones set halfway between and 2 to knee flexes and reaches the forward
tape are placed 2 ft apart, forming a 3 ft across (Figure 11). The lateral cone with a natural step length. The
square. The athlete stands with both speed weave is designed to promote lateral and backward movements re-

ning or agility sports. The two pre-

ferred knee systems for athletes are b
the Mauch Swing'N'Stance (SNS) d
type hydraulic or S-type Swing Only v
hydraulic knee (Figure 13) (Mauch a
Laboratories, Dayton, OH) or the t
Otto Bock 3R55 modular polycentric s
axis joint with hydraulic swing-phase
control (Otto Bock HealthCare) (Fig-
[j (J ure 14). The Mauch hydraulic cylin-
der uses a single-axis frame, and the
/J SNS offers athletes a wide range of re-

sistance adjustment to stance control.
Most competitive athletes, however,
(J use the S-type Swing Only hydraulic
unit because stance control is no
longer necessary with athletes who
Figure 12 Agility drill. (Copyright © Advanced Rehabilitation Therapy, Inc, Miami, FL, are successful runners. The Otto Bock
2002. Illustrator Frank Angulo.)
3R55 polycentric axis joint is a favor-
ite for knee disarticulation athletes
quire that the prosthetic knee remain amputee must also achieve and main- because of the instantaneous center of
straight. The athlete can keep the tain cadence speed during the swing rotation capabilities of a four-bar de-
knee straight by maintaining hjp ex- phase. Hydraulic knee uruts offer the
sign, providing increased toe clear·
tension force against the back wall of ability to adjust the hydraulic resis- ance and greater stride symmetry.
the socket, even as the sound limb is tance of knee flexion and extension to
Learning how to maximize knee
taking a step backward. keep pace witl1 the runner. During
performance during running requires
running, lowering the hydraulic exten-
Agility Drills transverse rotation of the pelvis to
sion resistance permits faster knee ex-
generate a full stride length and to
For agility drills, 28 several cones or tension, wrule increased flexion resis-
strike the ground with a backward
cups should be lined up in two rows tance decreases the amount of heel rise
force during the support phase (as de·
approximately 6 ft apart (four to six for novice runners. Seasoned runners
scribed in Table 2) . For lateral move·
cones on either side). The athlete set tl1e resistances to achieve symme-
n~ents, keeping the prosthetic limb
should move quickly from one cone try between limbs. Knee flexion resis-
slightly posterior to the sound limb
to another, squatting down to touch tance should be set low enough to al-
will keep the weight line anterior to
each cone while zig-zagging from one low sufficient time for the hip to
the knee joint, ensuring a knee exten-
cone to another. The key to this exer- achieve full flexion. If there is too little
sion moment to decrease the risk of
cise is maintaining speed by staying resistance, the knee will flex too
knee buckling.
on the toe of the prosthetic foot and quickly, resulting in insufficient time
using the quadriceps and hip extensor for the hip to generate maximal power
muscles to rapidly extend the pros- to move body weight over the con- Ancillary
tralateral limb, thus reducing running
thetic limb while corrung up from the
speed. Extension resistance is opti-
Components
squatting position (Figure 12).
mized when the limb comes forward Shock absorbers are tl1ought to re·
smoothly into the float phase. duce ground-reaction forces. This can
Prosthetic Knee A transfemoral amputee can learn be a tremendous benefit for athletes
Options the basics of running on almost any who run long distances or participate
type of knee system. However, in high-impact sports. Because shock
Transfemoral amputees have addi- friction-control knees are too slow to absorbers also absorb an u11deter·
tional considerations when learning to respond to any speed greater than a mined quantity of energy, they do not
run with a passive prostl1etic knee. To fast walk, and prosthetic knees with- return much stored energy, which re·
date, no knee system provides suffi- out some type of stance control are duces acceleration as the athlete
cient controlled knee flexfon during not recommended to teach running moves into the swing phase. As a re·
the prosthetic support phase of run- as they are not designed for running suit, many athletes who participate in
rung, so the residual limb must absorb and are not safe. Pneumatic systems high-speed sports elect not to incor·
the ground-reaction forces during ini- are also not sufficiently cadence- porate a shock absorber into their
tial ground contact. The transfemoral responsive for the demands of rw1- sport prosthesis.

Ch apter 51: Physical Therapy for Spor ts and Recreat ion 655
Torsion adapters are often chosen

by athletes who participate in multi-
directional sports such as tennis or
who generate rotation about the long
axis, as in swinging a golf club. Theo-
retically, torsion adapters reduce the
shear forces within the socket and
permit greater rotation for improved
performance. Not all individuals who
participate in tennis or golf find the
added motion beneficial. Some find
the additional motion difficult to
control or conclude that the benefits
do not outweigh the additional
weight and maintenance.
Knee rotation adapters allow the
amputee to move the foot and shin
components into a variety of posi-
tions that would otherwise be impos-
sible. For example, to facilitate recre-
ational activities that involve sitting, A
such as gardening, just being able ~
move the foot out of the way is very Figure 13 A. Mauch SNS type hydraulic knee. (Courtesy of Ossur, Aliso Viejo, CA.) B,
helpful. Knee rotators also facilitate Mauch SNS type hydraulic knee used w ith transfemoral amputee runners. (Courtesy of
Advanced Rehabilitation Therapy, Inc, Miami, FL.)
greater ease with dressing, changing
shoes, and similar routine tasks.
Specific Sport
Considerations
Swimming
Swimming is both a competitive and
recreational sport enjoyed by ampu-
tees of all ages. The freedom of the
water, cardiovascular benefits, and
muscular endurance gained from
swimming make it a nearly ideal ac-
tivity. Competitive swimmers are not
permitted to wear a prosthesis while
competing, so these athletes learn to
swim extremely well unaided. When
first learning to swim, lower limb am-
putees may experience some difficul-
ties, such as drifting toward the am-
putated side when kicking with the
Figure 14 A, Otto Bock 3RSS modular polycentric axis joint with hydraulic swing phase.
sound limb. Others describe difficulty
(Courtesy of Otto Bock HealthCare, Minneapolis, MN.) B, Otto Bock 3RSS used w ith
in maintaining their tnmk and shoul- transfemoral and knee disarticulation ru nners. (Courtesy of Advanced Rehabilitation
der parallel to the water surface, thus Therapy, Inc, Miami, FL.)
reducing their speed and requiring
additional exertion to propel through
the water. On the whole, however, Advantages to wearing a prosthesis shower facilities and to facilitate pool-
most amputees young and old learn during swimming include having two side activities. In addition, the pros-
to swim easily. limbs to enter and exit the water and thesis can add propulsion during

TABLE 3 Considerations for Golf for Amputees 1

Putting
There are countless aspects to putting, from stance to club selection F
p
For the purpose of th is exercise, the classic pendulum-type stroke ha's
been selected. s
Stance s
0
The golfer should set up with a comfortable, wide stance, wit h the ~
knees slightly bent. Transfe moral amputees should keep the prosthetic
knee straight with the sound limb slightly f lexed, if possible. Weight
should be balanced over the center of the feet, w ith a little more
we ight on the front foot. The upper arms should rest lightly on the
trunk, and the eyes should be directly over the ball.
Stroke
Hands, arms, and shoulders all work together to create a
pendulum-type stroke. Shoulders and arms create a triangle that
moves an equal distance on both t he backswing and the
through-swing, with the head rema ining still at all times.
Prosthetic foot
The golfer should feel the points of the heel, little toe, and great toe
on the prosthetic foot. This wi ll help balance the weight over the foot.
Starting with we ight distributed equally over both feet, the weight
should move slightly toward the forward foot, whet her it is the
prosthetic foot or t he sound foot.
Exercises
A helpful exercise is to start with short, 3-ft putts and progress to
longer and longer putts. Golfers should focus on maintaining the same
swing wh ile creating a stable base within the lower body. 28 As shown
in the illustration, most of the golfer's body we ight should be over the
shaded box on the lower scale.
Benefits
_.__.___,1_--=---=.
_ -=L J ,--,- -1- -1 ,- -, Besides improving the putt ing game, this exercise helps the amputee
work on prosthetic we ight bearing, develop a sense of how the weight
is distributed over t he prosthetic foot, connect the body and foot to
the ground, and challenge standing balance. This exercise also begins
the process of differentiation of the t runk from the pelvis, which aids
in arm swing during wal king and other sports.
Chipping and Pitching

Getting on the green and close to the hole can reduce any golfer's
score dramatical ly. Chippin g and pitching is all about balance and
repeating the same stance and stroke over and over.
Stance
The golfer should set up wi1h a narrow, open stance, positionin g the
feet fairly close together. Tne forward foot is slightly back and the
body is aligned slightly left of t he target. The ball is positioned toward
the back foot with a fair amount of we ight on the forward foot. Knees
are slightly f lexed with the back straight and the hips flexed a little.
Stroke
The hands move ahea d of the ball, with wrists firm (no bending) and
with t he body's we ight moving toward the forwa rd le~. The distance
the ball goes is dictated by th e distance of the backsw1ng and
through-swing. Both movements are usually equal in distance. A short
chip requires only a short backswing and through-swing, whereas if
the ball needs to fly fart her to reach the green, a more complete
stroke is required, along with a little wider stance.
Prosthetic foot
Getting t he weight down into the prosth etic foot is essential for
consistently successful chipping and pitching. A prosthetic foot that
perm its vertica l as we ll as rotational shock absorption can make this
stroke much smoother and more comfortable, especially when the
prosthetic limb is forward.
Exercises
After getting comfortable with motion and weight-shifting without
using a golf club, golfers should practice using a sand wedge and
perform the same mot io n. They should hold their f inished position
with the clu b raised and t heir body we ight well forward. Because golf
courses are neither flat nor firm, it is helpful to create a practice
condition using the sam e stroke with a golf club and with a foam
cushion under both feet whi le holding the f inished position. 28 As
c=::1- -r::=:i- ~ I shown in the illustration, most of the golfer's body weight should be
over the shaded box on the lower scale.
Benefits
This exercise allows golfers to start getting the ball in a better position
to reduce t he number of puttin~ strokes. They wil l also notice .
improved weight shifting, stability, and balance over the prosthe~1c
limb in various positions. As leg strength and balance improve, bigger
swings w ill become easier.

TABLE 3 Considerations for Golf for Amput ees (Cont.)
full Sw ing
A smooth, full swing wil l add distance and accuracy to any golfer's game.
Stance
Setup should be with feet shoulder-width apart and turned outward slightly. The knees should be bent slightly until weight is over the center
of the feet. Transfemora l amputees w ill need to keep thei r prosthetic knee straight and, as a result, the sound knee w ill be straighter as we ll.
Hips should be slightly flexed, keeping the lower back straight and chin up.
Stroke
The classic backswing is a smooth, seamless tu rn, moving the club, hands, arms, chest, and shoulders together, sweeping the club head back and
low w ith a fu ll and wide swing. Weisht should be maintained on the inside of the back foot with the front foot firmly on the g round. For the
downswing, the lower body should initiate the movement as the body unwinds, and the hands should remain soft as the club head moves
through the ball. Golfers should shift their body weight smoothly from the back foot to the front foot. The body should rotate all the way
through the shot, with most of its weight f inishing over the front leg.
Prosth etic foot
As the magnitude of the 9olf swing increases, the need to have a sense of where the prosthetic foot is also increases. The more golfers can
"feel" where the weight 1s d istributed over the prosthetic foot, the better their balance and swing cont rol will be. Also, the greater the forces
that are generated throughout the prosthetic limb, the more a shock absorber or torsion contro l device wi ll reduce the forces and offer greater
mobility and comfort.
Exercises
To practice for fu ll swings, golfers should start with a half swing and progress to a three quarters swing and then a ful l swing. They should focus
on shifting the weight between the feet. Weight should be kept toward the inside of the back foot during the backswing, allowing t he we ight
28
to move to the front foot during follow-th rough. Golfers should hold the follow-through position for a couple of seconds. As shown in the
illust ration, most of the golfer's body we ight should be over t he shaded box on the lower scale.
Benefits
Maintaining a stable base not only improves the amputee's golf game, but also improves prosthetic control during everyday activit ies and
wa lking. Controlling both the backswing and follow-through will build eccentric or deceleratory strength througnout both lower limbs,
especially w ithin the socket. As club head speed improves, the need for greater strengt h and balance will also increase .
c::iL--__.__ _ ..__ _.c=L.--

- 1
Initial Setup Backswing Downswing Follow-through
(Copyright © Advanced Rehabilitation Therapy, Inc, Miami, FL, 2002. Illustrator Frank Angulo.)
swimming or wading. Amputees who ing a prosthesis while in the water. pendently. Many public and private
have problems with limb volume fluc - Wheelchair-mobile amputees may re- pools are being equipped with Hoyer
tuations may also have difficulty don- quire assistance to get into and out lifts as a result of increased public
ning the prosthesis after swimming of the pool if they are unable to per- awareness and pubUc policy such as
and may therefore benefit from wear- form floor-to-chair transfers inde- the Americans With Disabilities Act.

Golf control all the movements with an ac- pinched between the socket and the
tivity as complex as a golf swing will saddle. A racing saddle is generally TJ
Good balance and the ability to shift
weight are two key skills necessary to make everyday activities seem sim- used for t his reason because of its Li
play golf well. Training for both of pler. Using prosthetic components narrow design. Some riders initially Tr
these skills can begin early during re- that assist with shock absorption and choose a woman's saddle for the s~
habilitation and continue at home torsion control can reduce the shear added balance obtained by a wider S1
until the amputee is ready to return forces within the socket and help cre- posterior portion. Soft-tissue pinch - M
ate a more stable base of support being may be greatly reduced with the e1
to the driving range. Consistently tr
tween the foot and the ground. Con- addition of a padded seat cover and a
practicing trunk rotation and weight R•
siderations for golf for amputees are well-padded pair of cycling shorts.
shifting will help develop balance and D
outlined in Table 3. The thinner, more flexible polyethyl- di
ambulation skills to prepare the am-
ene plastic sockets also aid in main- cc
putee to return to the golf course. Cycling taining balance on the bike and re- R,
The mechanics of the golf stroke
Cycling affords the amputee a chance ducing pinching. In
are relatively individual to each golfer. u
to enjoy speed and cover great dis- Although most competitive cyclists
The amputee will invariably lose dis- a1
tance. Many amputees choose cycling prefer to ride with their prosthesis for a1
tance on the swing; however, if the
as a form of exercise because it offers the added power of using both legs, c
swing keeps the ball in play or on line,
excellent aerobic conditioning with- many transfemoral amputees find it A
then the golfer's objective has been
out the high impact on tl1e residual more comfortable to ride without it. Sf
met. The key to teaching amputees to d
limb that occms during running. An- They simply remove the pedal on the
golf is that they play within their own other advantage is that little is re- v
prosthetic side and use a toe clip on
individual limitations; this means that quired in the way of adaptive eqttip- v
the sound side to apply power on
they need to learn to maintain bal- e:
ment for any level of lower limb both downward and upward strokes b
ance and weight shift whether they amputation. of the pedal. p
are standing or swinging from a Amputee cyclists of all levels may c
wheelchair. have difficulty in achieving maximum IV
Assistive devices in golf and the power when they push downward on Preparing the 0
a·
manner in which golfers choose to the pedal. Biomechanically, the best Amputee for
play are almost as varied as their golf way to achieve optimum power is to
strokes. Many amputees prefer not to
Recreational and
place the prosthetic shank directly
Competitive Sports u
wear a prosthesis; others use a wheel- over the pedal, unlike the intact side, l'v
chair, tripods, or other devices to lean where the metatarsal heads are cen- Cilinicians, such as physical therapists 11'
on as they swing. Some amputees a·
tered on the pedal. Recreational riders and prosthetists, often play the role of ti
who do wear their prosthesis and should simply place the midfoot di- coach early in the rehabilitation pro- B
stand independently prefer some type rectly over the pedal. Competitive cy- cess as the athlete with a disability A
of rotator or swivel device, but others clists who desire to use the power of prepares to return to athletics. One of a
find the additional weight or rota- the residual limb during both down- the most common obstacles to suc- A
tional movement to be a disadvan- ward and upward strokes will use a cess is the lack of knowledge among c
tage. A number of golfers will take the toe clip to hold the prosthetic foot in athletes, coaches, therapists, prosthe· E
spikes out of their golf shoes so that place. To fit the forefoot into the toe tists, and parents about how to en- E
the shoes will be able to rotate di- clip and still position the shank over comage amputees with athletic posi
rectly on the ground. n
the pedal, amputee cyclists may cut tential to improve their performance
Golf is one of the most popular the prosthetic forefoot off or use a toe or to begin participating in a particu·
sports enjoyed by amputees of all clip that provides extra depth. lar event. Often the easiest and most
ages, levels of amputation, and func- Transtibial amputees generally ex- frequently used approach is "Just get
tional abilities. Very few recreational perience m1mmum difficulty in out there and try it! "
activities encourage people to get out- riding with a prosthesis, but addi- Ideally, a qualified coach would in·
side, compete within their comfort tional suspension may be needed, for struct the athlete in the proper skills
level, and enjoy social exchange with e
which there are many alternatives. For necessary for a given event, and with
friends the way golf does. Interest- c
transfemoral amputees who ride with time and training the athlete would
ingly, golf is also one of the most ben- their prosthesis, seating and hip range comfortably return to the sport. Un-
eficial activities that anyone can use of motion present the greatest prob- fortunately, this is rarely the case. Be-
to in1prove balance, coordination, lems. The transfemoral amputee cy- cause of the small number of arnpu·
range of motion, strength, and endur- clist requires a saddle that is wide tee athletes in any one region, coaches
ance. In many ways, golf is the perfect enough to balance upon yet narrow rarely have the opportunity to work
rehabilitation therapy. Being able to enough so that the upper thigh is not with them enough to develop any real

TABLE 4 Tips for Coaching the Novice Disabled Athlete
Listen to the athlete.

Training with disabled athletes must be a cooperative effort. No absolute system of training has been developed, so novice coaches
should listen to the athlete and discuss and develop technique variances together.
seek out other disabled athletes competing in the same sport.
Most of the development in equipment and performance techniques has been achieved through the experiential knowledge and
efforts of the athletes themselves. Many of the t op coaches are disabled athletes, either retired or st.ill competing. In addition, a
training partner can also help to make the practices easier.
Recruit able-bodied coaches.
Disabled coaches are often difficult to find. Many elite disabled athletes train with able-bodied sport teams and athletes under the
direction of able-bodied coaches. Often, the coordinated efforts of a coach and a therapist who are aware of the abilities and
constraints of the athlete's physical capabilities work well when the disabled athlete wants to improve technique.
Read texts and publications pertaining to both able-bodied and disabled athletics.
In recent years, there have been a number of significant contributions to the body of literature concerning disabled sport.
Unfortunately, there is still is a tremendous void in many particular sports and for many specific disability groups. However, ·reading
and learning about able-bodied training methods and techniques is still an excellent way to gain insight into how to train a disabled
athlete in a particular sport.
Call th e appropriate disabled sports organizations for information and names of people to assist w it h t raining.
All disabled sports organizations maintain some form of database for a variety of topics, including athletes and coaches. Disabled
sports organizations are generally underutilized as resources and should be contacted to assist w ith providing athletes and coaches
direction in the training process.
Videotape practices and competitions.
Viewing videotapes of practice sessions and competitions for immediate visual feedback or for more detailed critique later is an
excellent method of instruction. Moreovtr, videotapes of elite competitors with similar disabilities help the athlete visualize the
biomechanics of accomplished performance. Coaches should caution athletes not to imitate other athletes, however. No two athletes
perform the same way; therefore, young athletes should be wary of imitating movements of even celebrated elite athletes.
Consult with technical experts about adaptive equipment.
Many disabled athletes use adaptive equipment such as wheelchairs, prostheses, orthoses, and other assistive devices. Prosthetists,
orthotists, biomedical engineers, and other adaptive equipment specialists can provide specially designed equipment to meet the
athlete's individual needs and enhance performance. Only a few clinical professionals specialize in disabled athletic adaptive
equipment because of the infrequent demand. Because poorly fitting equipment can be more harmful than helpful and in some cases
even dangerous, the coach and athlete should make an effort to seek out and collaborate with one of these clinical professionals.
Use motivational techniques to help maintain the athlete's interest in training and the sport.
Maintaining an athlete's level of intensity when training for a sport can sometimes be a rea l challenge. A wide variety of literature,
motivational tapes. and other resources is available to coaches who are interested in the inspirational aspects of coaching. As with any
athlete, maintaining a balance between level of difficulty and level of frustration is important. Continuing to experience success w ith
training and competition is positive reinforcement that will ensure that the athlete continues in the sport.
Become familiar with the rules or rule changes t hat may influence performance techniques.
As disabled sports evolve, classifications, rules, and competition formats will continue to change. Athletes and coaches alike must keep
abreast of these changes to prevent any last-minute confusion and alterations in competition strategies.
Attend conferences for coaching both able-bodied and disabled athletes.
Conferences and seminars are excellent fo rums in which to exchange ideas and learn innovative approaches to sport techniques.
Experiment with new techniques.
Experimenting with new and unique techniques may help overcome a particular obstacle or enhance performance. Be careful of new
styles that emerge from a single athlete as they may lack mechanical advantages and provide only a psychological edge. Keep an open
mind, however. ·
Maintain written records.
Keeping journals of training sessions and competitions provides a log that may be reviewed by the coach and the athlete to determine
trends that may enhance or hinder performance. There is also a tremendous need for the publication of positive and negative
outcomes with regard to athletic performance to assist other athletes who are in similar situations.
expertise. There are several excellent athletes, parents, interested able- disabilities, coaches must build on sev-
coaches for amputees in the United bodied coaches, and clinicians. eral sources of knowledge and synthe-
States, many of them current and Most coaches of athletes with dis- size them for practical application to
former competitive athletes, but only abilities have to become extremely re- the athlete's training. This problem-
a small number of developing athletes sourceful in working toward enhanc- solvin g approach to training can be
have the opportunity to work with ing the athlete's performance. Because the most exciting and rewarding as-
them. As a result, most amputee ath- little information is available specific pect of coaching disabled athletes. The
letes must rely on themselves, other to sports performance in persons with coaching tips outlined in Table 4 ap-

proach can be used to successfully References amputation or impairment. J Rehabil

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1. Yigiter K, Sener G, Erbahceci F, Bayar
I 5. Cavanagh PR (ed ): Biomechanics of
K, Viger OG, Akdogan S: A compari-
Distance Running. Champaign, IL, Hu-
Conclusion son of t raditional prosthetic training
man Kinetics, 1990.
versus proprioceptive neuromuscular
A person who is interested in partici- facilitation resistive gait training with 16. Alexander RM: Elastic Mechanisms in
pating in sports typically maintains transfemoral amputees. Prosthet Animal Movement. Cambridge, En-
enthusiasm for athletics long after Orthot Int 2002;26:213-217. gland, Cambridge University Press,
losing a limb. Health care profession- 1988.
2. Gailey RS, Ga iley AM: Prosthetic Gait
als and athletic coaches can assist am- Training Program for Lower Extremity 17. Ounpuu S: The biomechanics of walk-
putee athletes to return to sports with ing and running. Clin Sports Med 1994;
Amputees. Miami, FL, Advanced Reha-
13:843-863.
a few minor adaptive modifications bilitation Therapy, Inc, 1989.
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3. American College of Sports Medicine:
reaction forces in distance runni ng.
Providing the opportunities and assis- Guidelines for Exercise Testing and Pre-
J Biomech 1980;13:397-406.
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19. Hay JG: The Biomechanics of Sports
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Techniques, ed 3. Englewood Cliffs, NJ,
dard rehabilitation program. Al- 4. Linn BS, Linn MW: Objective and self-
Prentice- Hall, 1985.
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Soc Sci Med 1980;14A:311 -3 15. 20. Mann RA, Moran GT, Dougherty SE:
how long it will take an amputee to
Comparative electromyography of the
heal and adjust to the loss of a limb, 5. Goldberg G, Shephard RJ: Personality
lower extremity in jogging, running,
proper training should be available to profiles of disabled individuals in rela-
and sprinting. Am J Sports Med 1986;
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Therefore, clinicians should either be JSports Med 1982;22:477-484.
21. Nuber WN: Biomechanics of the foot
able to assist the amputee directly or 6. Lamb KL, Roberts K, Brodie DA: Self- and ankle during gait. Clin Sports Med
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fer the amputee to a suitable program pants and non-sports participants. Soc
22. Czerniecki JM, Gitter A, Munro C:
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Joint moment and muscle power out-
7. Bernstein LC: Aging: The Health Care put characteristics of below knee am-
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Davis Co, IY9U. of energy storing prosthetic feet.
Manufacturer List
Mauch Laboratories
3035 Dryden Road
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elders with amputation. Top Geriatr
Rehabil I 992;8:39-58.
9. Gailey R, Gershon S, D'Esposito T,
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recreation for those with lower limb

Research in Lower Limb
Prosthetics
Saeed Zahedi, OBE, FIMechE
Int roduction
Rapid technologic advances in lower duce peak pressures and increase am- based on static measurements. The
limb prosthetics have occurred since putee comfort. Advances in material availability of low-cost dynamk
the early 1990s. Paradoxically, these technology have led to the use of transducers combined with an in-
advances have been concurrent with novel polymers in the manufacture of creased understanding of soft-tissue
an estimated 20% reduction in fund -' socket liners and to the creation of mechanics has resulted in new con-
ing for amputee care. Despite the ever thinner, lighter, and stiffer sock- cepts in amputation surgery, pros-
technologic improvements in compo- ets for transmission of weight-bearing thetic socket design, and the use of
nents and materials, studies from Eu- loads. Alternatives such as direct skel- new materials to enhance control of
rope and the United States suggest etal attachment via osseointegration the prosthesis by the amputee. In-
that overall amputee satisfaction with and limb transplantation are being creased control of the prosthesis re-
prostheses has remained relatively explored as alternatives to the use of quires and facilitates improvements in
constant, varying from 70% to 75% of external prostheses. prosthetic components and has refo-
those polled. In the 1990s, the combination of cused efforts on enabling the amputee
In the second edition of this Atlas, amputees' expectations and industrial to engage in a full ra11ge of normal ac-
Charles Pritham postulated that pend- competition resulted in many new de- tivities of daily living.
ing decreases in academic research in velopments in lower limb compo- The recent growth of regulatory re-
prosthetics might force commercial nents. US companies combined ad- quirements and the development of
component manufacturers to divert vanced prosthetic feet with various
International Organization for Stan-
profits into increased product research shock-absorbing systems, while Euro-
dardization (ISO) testing protocols for
to fill the void. The accuracy of that pean firms took the lead in developing
endoskeletal lower limb prosthetic
prediction was borne out during the novel components such as a rotary hy-
components have enhanced the stan-
1990s when published research from draulic knee and microprocessor-
dards for the manufacture of high-
universities and government research controlled knee mechanisms. Rapid
quality products that are safe and reli-
organizations dropped dramatically. growth and consolidation of pros-
thetic component manufacturers able yet economically competitive.
Since the early 1950s, virtually all ap-
worldwide also characterized this de: Centralized fabrication-the use of
plied research has come out of the
cade, often through the purchase of technology to provide an economic
commercial sector- new suspension
options, innovative socket configura- young and innovative companies by and professional advantage-has been
tions, advances in knee mechanisms, established and better funded firms. suggested as one strategy for coping
and guidelines for prescription and re- This consolidation has created several with diminishing health care funding
imbursement of prostheses. major multinational competitors with for rehabilitation. More extensive use
Increased understanding of the sufficient sales to privately fUJ1d ongo- of computer-aided design and manu-
biomechanics of locomotion coming research activities. facturing has also been offered as a
bined with clinical experimentation method to deliver care with fewer fi-
have led to a steady evolution in lower nancial resources. Although both
limb socket design. Modern sockets
Current Developments trends have increased in clinical prac-
generally emphasize diffuse rather Before 1990, most information about tice, further integration of these two
than localized weight bearing to re- socket-limb interface pressures was concepts into one cohesive alternative
American Academy of Orthopaedic Surgeons 66 1

components. Proprioceptive feedback silicone rubber for improved dynamic

to current on-site manual fabrication
and sensations of comfort/discomfort response. As with earlier studies,
can be anticipated.
largely determine whether the pros- modifications to the socket were re-
thesis feels as if it is an integral part of quired to accommodate the trans-
Computer-Aided the body. These issues are all func- ducer. Maximum dynamic values of
2
Prosthetic tions of the limb-socket interface and approximately 175 kN/m were ob-
illustrate the importance of this sub- tained at the bri m of tramfemoral
Laboratory Concepts jective aspect of prosthetic care. sockets. Corell6 selected a similar yet
The concept of the computer-aided The desire fo r the best possible fit- Jess expensive sensor but reported
prosthetic laboratory (CAPL) was ting has led to widespread acceptance problems with repeatability. Rae and
first described in the 1990s but has of the use of a clear test socket. Test Cockrell,7 Pearson and associates, 8
not yet been fully realized in prac- sockets are used to evaluate the accu- and Burgess and Moore9 reported
tice. Potential applications for such racy of casting and rectification per- studies using strain gauge transduc-
knowledge-based concepts in routine formed by the prosthetist before the ers. Redhead 10 used silicone-etched
clinical service include the routine final socket is manufactured and to diaphragm transducers that required
scanning of both limbs as the ampu- obtain sufficient information on extensive modifications to the socket.
tee enters the clinic and assessing the present methods of casting and recti- Meier and associates 11 used capaci-
amputee's gait; CAPL could then sug- fication. This information is then tance transducers of relatively large
gest the appropriate type of ankle, used to improve methods of casting dimensions (20-mm diameter, 2-mm
foot, knee control, and alignment. and rectification. Furthermore, the thickness) to investigate the interface
Once the residual limb geometry is use of test sockets is intended to pro- pressure in transtibial prostheses.
scanned, the amputee's ability to vol- duce accurately and correctly fitting O ther investigators have used hydrau-
untarily control the prosthesis could sockets with very close tolerances so lic pressure transducers and hybrid
be assessed. CAPL of the future could that the fitting of hard sockets can be electro01c. trans d ucer sys t ems. 12, 13
make a diagnostic socket using rapid facilitated. The current generation of pressure
prototyping methods with integrated Limitations to this method include transducers and miniature force
sensors, ready for fine adjustments by the largely static nature of most test strain gauges offers new opportunity
the prosthetist. A custom protective- sockets, as well as the qualitative na- for dynamic measurements of the
cosmetic system could then, in theory, ture of the data used to evaluate skin-socket interface. Only recently
be manufactured while the amputee's socket fit. These limitations have led have transducers using electrotextile
socket is being fitted. investigators to exam ine pressure materials been developed, facilitating
CAPL of the future would record magnitudes and variations at the ~ressure-force measurements at the
all data and deliver the completed limb-socket interface, particularly un- interface without modification to the
limb in one session and would be ca- der dynamic walking conditions. existing socket. Various studies focus-
pable of making exact replicas at any Early studies were of limited value ing on the dynamics of interface me~-
later time. CAPL might also control because of the shortcomings in avail- surements are currently underway in
central inventory, arranging just-in- able measurement technology. Early North America and Europe.
time delivery of required components investigations measured dynamic for- The acquisition of limb-socket in-
and materials. Furthermore, because ces at the interface using a pneumatic terface pressure data has important
the need for casting is eliminated, am- transducer that measured pressure implications for improving socket. de-
putee perception of the prosthesis over a relatively la rge area of sign, especially in computer-aided
might be enhanced, and labor costs 25 cm.2 Boni 1 developed an improved design/computer-aided manufactur-
would be reduced compared with the transducer in the 1960s that coming (CAD/CAM) applications. In the
present reality. prised silver electrodes bonded to a future, in vivo data might be pro-
conductive rubber; the transducer grammed to control socket design
had a 9/16-in diameter and was ap-
Limb-Socket proximately 1 in thick.
and manufacturing.
Interaction In their extensive studies on inter- Testing of Interface
The primary requisite for successful face pressures, Appoldt and asso- Pressures During
use of an artificial limb is a comfort- ciates2·5 used strain gauges of various
Locomotion
able, secure, and well-fitted socket. configurations and manufacture be-
fore finally opting for diaphragm- In an effort to evaluate interface pres-
Secondary requirements to gain full
mounted semiconductor strain sure transducers under dynamic con-
benefit from functional components
gauges wired in a full bridge config~- ditions and concurrently determine
are the amputee's willingness for re-
ration. This transducer, only 0.02 m the quality of fit between res1'd ual
habilitation and optimum biome-
thick, was encapsulated in a droplet of limb and socket, I carried out tests on
chanical alignment of the selected

Chapter 52: Research in Lower Limb Prosthetics 663
TABLE 1 Average Peak Interface Pressures (kN/m 2 ) for Transtibial Amputees

Patient 1* 2* 2 3* 4 5 6 7
Test A Test B Test A Test B
Transducer
position
Patella bar 375 223 189 180 204 214 124 266 104
Fibula head 40 110 51 20 20 215 38 26 83
Medial hamstring 93 43 31 Fail 52 151 95 23 25
Lateral hamstring 49 15 40 18 Fail 108 55 N/R+ 58
Distal end of tibia 0 24 0 0 0 0 0 50 0
Midposterior calf 201 108 121 130 94 45 119 253 138
Subpopliteal fossa 88
Lateral tibia crest 123 160 156
Suprapatellar bar 74
* These results were recorded using a hardwire method. All other measurements were made via the a-channel amplifier and MTS
telemetry system.
+ Subpopliteal site selected instead of lateral hamstring
The run-to-run variation in pressure at the various transducer sites was a maximum of ±11 % but was less than ±6% at five of the sites,
thus w ithin t he standard deviation of the mean of the Force Sensing Resistor transducer.
•
nine healthy male amputees ranging
TABLE 2 Average Peak Interface Pressures (kN/m2 ) for Transfemoral Amputees
in age from 30 to 60 years. Day's 14
amputee activity assessment forms Patient 8 Patient 9
were used. Results showed a range of Transducer site
reported activity from moderately to lschial tuberosity 325 345
highly active. The socket designs of Lateral ischial seat 238 Fail
this group of transtibial and trans- Scarpa's triangle 72 70
femoral amputees varied. Midvastus lateralis 108 80
Distal anterior femur 0 68
Selection of Socket Anterior medial brim 255 120
Transducer Sites Greater trochanter N/A 350
Transducers were placed in the socket
around those areas considered as Th e run-to-run variation in pressure at the various transducer sites was a maximum of
± 11.37%; at five of the sites it was less than ± 10%, w itlhin the standard deviations of
pressure-sensitive and pressure-
the mean of the Force Sensing Resistor transducer.
tolerant. The rationale was that un-
usual pressures in these areas would
indicate a potentially poor fit of the
socket in that region. With the subjects are shown in Table 1. Al- As expected, the highest interface
transducer-fitted prosthesis donned thoug4 the range in peak pressure pressures were recorded at the ischial
and the associated pointer and telem- values was wide, the temporal pattern tuberosity transducer site, with only
etry equipment worn on a waist belt, of pressure buildup was similar for all 20 kN/m2 difference between the two
the patient was instructed to walk patients. patients. For both patients, the ischial
normally along a defmed walkway tuberosity transducer indicated load-
incorporating two Kistler (type ing throughout the gait cycle, with
926SIA) force plates. Results From Transfemoral
a constant load of approximately
Testing
140 kN/m2 registered throughout the
Results From Transtibial Interface pressures and ground- swing phase.
Testing reaction forces were measured and re-
Interface pressures and ground- corded for two transfemoral subjects. Discussion of Interface
reaction forces were measured and re- The average peak pressures at the var- Measurements
corded. Peak pressures at each trans- ious transducer sites are shown in Two patients had peak pressures at
ducer site for the seven transtibial Table 2. the fibular head transducer site in ex-

cess of 150 kN/m2; one of these was muscle, it is put into tension relative a conventional prosiliesis. 16 Despite
215 kN/m2, higher than the pressure to the w1derlying skeletal structures. more than 30 years of success in de- T
recorded at the patellar bar site. The This combination of effects results in veloping dental and maxillofacial im-
implication is that the fibular head is the push-off phase developing a plants and fitting more than 450,000
providing a horizontal reaction force higher peak pressure than that occur- patients with a 95% success rate, /J
as the body weight is transferred from ring during the initial shock- Branemark is being cautious in the c
the sound to the prosthetic side, con- absorbing phase. This characteristic use of osseointegration to attach S-
sistent with the maximum peak me- pattern of interface pressure at the lower and upper limb prostheses. S-
diolateral shear force measurements patellar bar is consistent with those The potential for osseointegration s
of the force plates. recorded by Isherwood,1 3 Pearson to provide more control over the c
An alternative reason for this and associates, 8 and Rae and Cock- prosthesis and increase the power c
anomalous result might stem from rell.7 Active knee extension at push- transfer between amputee and limb is
mediolateral instability. As a conse- off increases force on the anterior dis- great enough to provide significant
quence of this subject's short residual tal area and decreases pressure on the new challenges fo r prosthetic compo-
limb length, lateral stabilizing forces patellar tendon. nent design. More sophisticated de- c
applied by the socket may be less ef- My study illustrates the importance signs might include special mecha-
fective in controlling mediolateraJ in- of looking at socket interface pressures nisms for absorption of shock load le
stability. This patient showed consis- as a dynamic entity. In fact, assump- and axial rotational torque to avoid cl
tently high interface pressure readings tions made based on static models of direct transmission of these stresses cl
(> 100 kN/ni) at the proximal sites tissue mechanics now seem to be in- to the bone interface. Future research S,
within the socket but low interface correct. Most areas of the residual advances in prosthetics technology v
pressure readings ( < 50 kN/m 2 ) at the limb can tolerate much higher loads could involve the use of a micropro- 0
more distal sites. than expected if for a short duration cessor to provide closed-loop control
Interface pressures measured at the only. Tissue injury and discomfort of knee and a11kle movement and the
medial hamstring transducer site, probably arise primarily from pro- possibility of electromagnetic control
another proximal-pressure sensitive longed application of pressure, pre- and biofeedback, potentially leading n
area, were less tha11 90 kN/m2 for the sumably due to incorrect distribution to electromechanical suspension for c
two patients mentioned above. The of pressures within the socket. heavier prostheses. r,
cause of the high pressure values Limitations still exist, however. A c
could be the lack of knee stability in- Role of Osseointegration in mechanical fail-safe mechanism, ad- i.J
herent with short residual limbs. Future Lower Limb justable to different levels of activities, c
The interface pressure developed i~ essential to avoid loosening or
Prosthetic Research a
at the patellar bar transducer site breakage of the implant. The cosmetic
shows a characteristic double peak. Branemark and associates 15 described
appearance and psychological issues n
The initial peak, occurring shortly af- the use of implants for direct connec-
associated with osseointegration re- n
ter heel strike, is a result of the decel- tion of external prostheses to the skel-
eton via an internal prosthesis. Brane- quire specialized training. The reli-
eration of the center of gravity rela- ability and limited scope for repair,
tive to its position during the latter mark and his associates have been
developing this idea for many years. significant cost of the initial surgery v
part of the swing phase. During mid- and possible subsequent surgeries, and
Recently they published fairly success- p
stance, there is zero acceleration of feasibility of reverting to wearing con· 1:
the center of gravity; the axial load, ful results in both lower and upper
ventional prosthetic devices remain
and hence the patellar bar interface limb fitting. This concept of osseoin-
barriers to more widespread use of
pressure thus falls to a value corre- tegration is based on the use of pure ti-
tanium implants that, after a system- this method.
sponding to that produced by body
weight alone. Upon rollover and atic healing and weight-bearing
push-off, the absence of active plantar protocol, provide very good load- Increased Use of Soft 0
flexor muscle action causes the ampu- bearing properties. These implants .
Tissues for Force r
tee to apply active knee extension . have been tried in different sizes, vary-
The reaction force that is due to ing from partial finger to femoral Transmission le
sizes. In recent years, clinical exploration of s
acceleration of the center of gravity in
an upward drrection results in i11- This interface requires routine the ability of the soft tissues to serve as u
creased pressure at the patellar bar in- daily cleaning to reduce the risk of in- a medium for force transmission has ~
fection. Many transfemoral amputees resurged. This renewed interest is d
terface. This is likely to be further in-
creased by the a11atomic change to the using osseointegrated prostheses based on the similarity of the soft tis-
patellar tendon when, because of the demonstrate a wider range of walking sues to fluids; both are incompressible
extensor action of tl1e rectus femoris speeds than individuals walking with and can therefore transmit forces

in the casting situation, the soft tis- tions (Table 3). Interestingly, stopping
TABLE 3 Typical Daily Activities of sues change shape in response to the and standing with a stable knee is one
Lower Limb Amputees
equal pressure being applied. How- of the most frequent functions re-
Times ever, the shape of the socket needs to quired. The need to change walking
Activity per day be adjusted in order to minimize speed occurs more often than de-
Changes walking speed 437 pressure peaks that may occur in the scending stairs and ramps. The data
Stumbles 108 dynamic situation, by either conven- in Table 3 are from 15 amputees who
Stops a nd stands 1,450 tional relief or building a silicone wore an electronic knee that recorded
Sits 48 pressure pad into the surface of the these activities over a period of
Descends stairs 23 socket where a pressure peak is likely 3 months.
Descends ramps 38 to occur. Data such as these suggest that fu-
ture prosthetic knee joints must pro-
Review of Prosthetic vide stumble control-usually before
when properly constrained within a the amputee is aware of the need-as
container. Component well as support during stance to facil-
Prior studies have demonstrated a Developments itate slowing down. In addition, the
longitudinal internal piston action of Application of knee joint must alter the swing char-
the skeletal elements in the socket. In Microprocessor Control to acteristics for slow, preferred, and fast
theory, longitudinal movement of the walking speeds and provide stable
Lower Limb Prostheses
skeleton into the socket could be pre- support when standing. Additional
vented by the incompressible nature Research conducted in the early 1970s stability during stair and ramp de-
of the residual limb tissues contained, at the Massachusetts Institute of scent is also required. The specific
Technology (MIT) demonstrating the type of mechanism for achieving
within a rigid socket.
feasibility of using a computer to con- these requirements was created
To transmit force in this manner,
trol the prosthetic knee was dismissed through development of an adaptive
the soft tissues of the residual limb
as impractical at the time. In 1986, prosthesis. 18 If microprocessor con-
must be contained in a vessel that ac-
when Nakagawa 17 of Hyogo Rehabili-
curately matches the volwne of the trols or mechatronic solutions pro-
tation Center in Kobe, Japan, de-
residual limb. Various pressurized vide the most reliable and cost-
scribed a simpler application of mi-
casting systems have been developed effective solution, then prosthetic
croprocessor technology based on
in an effort to achieve this match. A component design will continue to
concepts developed at Osaka Univer-
combination of pressure casting with evolve in those directions.
sity, significant doubt still existed as
a silicone liner that is distally fixed to to the clinical acceptability of such
the socket has been proposed as one Microprocessor Control of
technology. It was not until the 1990s
method to achieve an efficient con- Hydraulic and Pneumatic
that the first commercial application
nection between the skeleton and the of microprocessor control to pros- Knee Resistances
socket. thetic knee mechanisms was de- All currently available prosthetic com-
Vacuum casting has also been ad- scribed. 18 ponents are passive systems- energy-
vocated, but its effect differs from The traditional viewpoint was that dissipating replacements for human
pressurized casting. When a vacuum the knee joint should be designed to limbs. Current power sources and ac-
is created only between the surfaces of provide stance control during the tuators have far too low a ratio of mass
the residual limb and the casting ap- weight-bearing phase of locomotion to energy capacity to actively power
paratus, no load is applied to the soft and swing control during the non- lower limb components under weight-
tissues even though the replication of weight-bearing phase. The swing bearing loads. Microprocessor-con-
the unloaded surface shape and vol- phase was perceived as a simple pen- trolled passive prosthetic knees are
ume are accurate. With pressurized dulum action, which required a lim- now clinically available worldwide;
casting, the shape and volume of the ited damping control during normal they offer a wider range of walking
residual limb are influenced by the walking activity that also enabled the speeds than earlier fluid-controlled
load applied to the soft tissues. The amputee to sit down. More recent re- systems tliat could be set by the pros-
soft tissues displace and stabilize the search has demonstrated that this thetist only for a fixed range of resis-
limb; the degree of displacement de- simpjjstic view of prosthetic knee tances.
pends on the load applied, which is function is inadequate. The requirements for prosthetic
determined by the casting pressure. My recent investigations have knee function during level walking
Pressurized casting is believed to shown that, during a typical day, a (Figure 1) are considerable. At heel
produce a volume-matched and lower limb amputee undertakes a strike the prosthetic knee must be sta-
surface-matched impression. At least number of standard repetitive mobilized as the foot begins plantar flex-

thetic knee. Key input signals are tbe

knee flexion angle, the angular speed
Deceleration
it[ f l ~ ~ elstrike
of the knee joint, and the anteropos-
terior bending moment of the shank.
A hydraulic cylinder generates the re-
quired resistances for flexion and ex-
tension control.
I have documented recent develop-
\{ ~ ot-tlat ments providing microprocessor-
Swing controlled pneumatic swing-phase
phase control. 18 Clinical experience with
40% Stance nearly 10,000 such devices has dem-
phase onstrated that microprocessor control
60% can optimize knee resistance over the
entire range of the amputee's walking
speed and result in a more energy-
efficient gait. The Intelligent Prosthe-
sis Plus (Charles A. Blatchford &
, ~ idstance Sons, LTD, Hampshire, England) uses
microprocessor control to optimize
pneumatic resistance to knee flexion
and extension during swing phase.
In 1996, my associates and I began
~ I-off
Toe-off
' - -- ~
work on the next generation of mi-
croprocessor control by analyzing the
activities that amputees undertake.
Figure 1 Phases of level walking.
Earlier research and development fo-
cused only on the primary function of
ion . During this load-bearing period, during which this range of knee mo- walking. Real-time monitoring dem-
the prosthesis has two major function must occur is very short. The onstrated that amputees undertake
tions-support of the body weight prosthetic knee should start with many activities in a day, including
and reduction in the impact of heel minimal flexion resistance and adapt 1;tandi11g, slowing down, walking at
strike. This is achieved by a yielding automatically to a wide range of gait various speeds, and descending ramps
speeds. At midswing, the shank and stairs. The project goal was to
flexion of the knee joint, which re-
changes the direction of rotation be- create a prosthetic knee capable of
quires high flexion resistance. During
adapting to different modes of loco-
the single-support phase, the body cause of mass- reaction forces and the
motion while optimizing the ampu-
moves over the stabilized leg like an knee starts to extend. The terminal
tee's voluntary muscle control and hip
inverse pendulum. During this phase, swing phase begins when the shank is
joint strength.
the ground-reaction force vector vertical and ends when the extended
This development provides stance
changes its position from heel to fore- leg hits the ground again. It is impor- control ranging from minimal resis-
foot. Because the flexed knee tends to tant that the knee joint extends tance to a yielding lock and is capable
extend rapidly, an appropriate exten- quickly so that the leg is fully ex- of detecting level walking, ramp de-
sion resistance is also necessary to tended, but the terminal impact scent, stair descent, sitting, standing,
prevent abrupt extension of the knee. should be minimal. and stumble conditions. The stance
This resistance should adapt to differ- This complex dynamic procedure resistance is set to a preprogrammed
ent gait speeds. At the end of single- can be best handled with an electron- level for these different modes, which
leg support, the maximum vertical ically controlled knee joint that pro- the prosthetist matches to the arnpu·
load is generated and knee flexion be- vides hydraulic resistance during the tee's level of voluntary muscle con-
gins shortly thereafter to prepare the extension elements of the swing and trol.
limb for swing phase. Therefore, the stance phases (Figure 2). The basic Rapid detection of different modes
knee resistance to flexion should be principle of this system is the detec- of locomotion is accomplished by the
minimal. tion of the current state of the ampu- use of microprocessor technology and
The swing phase begins with the tee's gait by integrated sensors and the a range of sensors detecting kinetic
knee already flexed 30°; the maximum immediate adaptation of the flexion and kinematic parameters aroun d the
knee angle is 55° to 65°, and the tin1e and extension resistances of the pros- knee. The prosthetist uses a remote

programming device to adjust and

fine-tune motor valve controls and to
adjust the resistance to flexion in
stance and swing in order to individ-
ualize the function for specific ampu-
tees.
The central concept in this knee
design is the creation of a prosthesis
that is accurately matched to an am-
putee's hip strength and ability to Knee angle sensor
control the limb in all modes of am• Vibration alarm
bulation. Clinical results suggest that
most active amputees are able to con-
trol the prosthesis during level walk- Hydraulic unit
ing but may need additional support Valve assembly
from the device when stopping or
during ramp and stair descent. Am- Ankle moment sensor -------""'.:>-.,,,,...
putees with limited hip power may
need stumble control during the initi-
ation of level walking. Most amputees
seem to benefit from the standing
mode, which allows them to relrut
without concern that the prosthetic
Figure 2 Sensors and electronic elements of the C-Leg system (Otto Bock HealthCare,
knee may collapse. Minneapolis, MN).
The Adaptive Knee (Charles A.
Blatchford & Sons, Ltd) combines the
proven swing-phase control from the tist to make continual minor adjust- taUy controlled. Not only the knee,
earlier Intelligent Prosthesis with a ments. Sensors generate a digital but also the ankle, foot, and leg socket
novel microprocessor-controlled hy- snapshot of the wearer's gait, which is will gather information from sensors
draulic cylinder that provides variable analyzed by onboard software. Damp- and receive instructions from a
stance stability fo r standing, stopping, ing of knee motion is performed by software-guided microchip.
stumble recovery, sitting, and stair or metal plates that are separated by an The intelligent hip joint described
ramp descent. iron-rich substance called magne- by Nakagawa 17 and a microprocessor-
torheological fluid. The microproces- controlled prosthetic foot described
Future of Microprocessor sor switches the magnetic field by Zahedi 18 represent the short-term
Technology arow1d the fluid on and off, altering future of microprocessor control to
The widespread clinical acceptance of the way the plates move past each complement available knee controls.
the integration of microchips into other and thus adjusting the resis- Use of Bluetooth technology for com-
prosthetic knee mechanisms sets the tance in the knee. munication between the ankle, knee,
stage for an exciting fut ure. The im- Funded by the US Department of and hip will make interactive control
mediate challenge is to increase pro- Energy, Sandia National Laboratories on a commercial scale feasible. For-
cessing power in order to create a has teamed with a group of Russian mulation of a standard protocol
prosthetic leg that can manage bal- nuclear scientists to develop a would enable prescription of different
ance, stability, and comfort on its microchip-embedded knee. German, feet, knees, and hip joints, regardless
own. Work on the third generation of Japanese, and British companies are of manufacturer.
"smart" prostheses has already been working on future versions of their
initiated by the main companies that own computer-controlled prosthetic Intelligent Prosthetic Hip
provide commercial microprocessor- componentry. In another project, the Joint
controlled knee prostheses. MIT's Leg Seattle Orthopaedic Group Inc (Seat- Hip disarticulation prostheses could
Laboratory, a research facility dedi- tle, WA; a private prosthetic compo- be improved by controlling the swing
cated to studying locomotion and re- nent manufacturer) and Sandia Na- of the hip joint. Careful observation
producing it robotically, is working tional Laboratories-again working and gait analysis have demonstrated
on a knee that will automatically with Russian researchers-aTe collab- that hip flexion angular velocity of
adapt as the amputee's gait changes, orating to create a smart integrated cunent prostheses is far slower than
eliminating the need for the prosthe- lower limb tl1at will be entirely digi- in normal gait, and mechanical means

tensities, commercial funding for re-

Chip Controller
search will also decline. Because gov-
Servo Valve ernmental support for prosthetic
research has been quite limited for
several decades, a significant reduc-
tion in privately funded research will
have a profound effect on the pace of
Power Ball innovation in future years.
Pump
Air Muscles
References
Figure 4 Microprocessor-controlled foot. 1. Boni G: Socket fit studies: An investi-
gation of the pressure patterns be-
tween stump and socket. Biotechnol-
dence. The ability of the frame to ab-
ogy Laboratory Technical Note No 25,
sorb shock loads and provide axial
Los Angles, CA, University of Califor-
rotation in a very low profile design nia, Los Angeles, May 1962.
makes this concept potentially suit- 2. Appoldt FA, Bennett L: A preliminary
Figure 3 Intelligent hip joint. This proto-
able for many lower limb prostheses. report on dynamic socket pressures.
type microprocessor-controlled pneumat-
ic hip joint allows hip disarticulation am- Bull Prosthet Res 1967;10:20-55.
putees to walk at varying speeds with less
Cosmesis Developments
3. Appoldt FA (ed): Pressure and Force
effort than is required with a mechanical For many amputees, a prosthesis with Measurement: A Report ofa Workshop
hip. a lifelike appearance is as important Sponsored by the Committee on Pros-
as its mecha11ical functionality. To- thetics Research and Development of the
day's patient often demands an exter- Division of Engineering and National
nal covering that in addition to pro- Research Council. Washington, DC,
to accelerate hip flexion have been National Academy of Sciences, 1968.
tecting the components is lifelike,
used clinically with some success. In durable, lightweight, feels like normal 4. Appoldt FA, Bennett L, Contini R:
one prololype (Figure 3), a pneu- Socket pressure as a function of pn:s-
skin, and is shaped and colored to
matic cylinder is compressed by the sure transducer protrusion. Bull
closely match the contralateral leg.
body weight of the user during stance Prosthet Res l 969;10:20-55.
Several manufacturers have devel-
phase. This air spring then accelerates ~- Appoldt FA, Bennet L, Contini R: Tan-
oped elastomeric coverings, often
thigh fJ.exion in early swing phase. gential pressure measurements in
made from silicone resins, that in- above-knee suction sockets. Bull
The compression varies depending on crease both the durability and cosme- Prosthet Res 1970;10:70-86.
walking speed and is controlled by sis of artificial limbs. Patient accep-
microprocessor positioning of the 6. Corell EB (ed): Normal Pressure Distri-
tance has been excellent, particularly
valve. This component allows hip dis- butions Applied by Total Contact Below-
for transtibial prostheses. Unfortu- Knee Prostheses. Ann Arbor, MI, Uni-
articulation amputees to vary their nately, when such coverings cross the versity of Michigan, Medical School,
cadence with less effort than that re- knee joint, they tend to restrict flex- Department of Physical Medicine and
quired with simpler mechanical hip ion, so additional research is required Rehabilitation, Orthotics Research
joints. to overcome this limitation. Project, 1969.
Microprocessor-Control led -7. Rae JW, Cockrell JL: Interface pressure

and stress distribution in prosthetic
Ankle-Foot Complex Summary fitting. Bull Prosthet Res 1971;10:
One concept for a prosthetic foot uses Commercially funded research ap- 64-111.
space frame technology for load pears to be on the verge of significant 8. Pearson JR, Grevsten S, Almby B,
structures and air muscles as primary technical advances that will improve Marsh L: Pressure variation in the
stiffeners (Figure 4). The power ball the comfort, control, function, and below-knee patellar tendon bearing
pump provides controlled ankle appearance of lower limb prostheses suction socket prosthesis. J Biomech
movement and·generates the air pres- in the coming decade. Whether this 1974;7:487-496.
sure needed to provide correct stiff- pace of development is sustained will 9. Burgess EM, Moore AJ: A study of
ness to the structure. This assembly depend largely on continued fw1ding interface pressures in the below-knee
can be loaded to absorb and restore for prosthetic rehabilitation. If the prosthesis: Psychological suspension.
energy at correct points in the gait cy- cunent trend of reduced support for An interim report. Bull Prosthet Res
cle and to respond to changes in ca- modern prostheses continues or in- 1977;14:58-70.

10. Redhead RG: Total surface bearing distribution, comfort, and brim shape. 16. Bergkvist R, Johansson S, Karlsson D:
self-suspending above knee sockets. BullProsthet Res 1980;17:35-50. Gait analysis of amputee with osseoin-
Prosthet Ort/10t Int 1979;3:126-136. 13. Isherwood PA: Simultaneous PTB tegrated lower limb prosthesis. Pro-
J J. Meier RH TI!, Meeks ED Jr, Herman Socket Pressure and Force Plate Val- ceedings of XIII International Interbor
RM: Stump-socket fit of below-knee ues. Preliminary Report, BRADU Congress. Oslo, Norway, 1996.
prostheses: Comparison of th1·ee [BiomechanicaJ Research and Devel- 17. Nakagawa A: Abstract Microprocessor
methods of measurement. Arch Phys opment Unit] Report, 1978, pp 45-49. control of hip joint functions. Book of
Med Rehabil l 973;54:553-558. Abstracts. 10th World Congress of the
14. Day HJB: The assessment and descrip-
J2. Naeff M, van Pijkeren T: Dynamic tion of amputee activity. Prosthet lnternationaJ Society for Prosthetics
pressure measurements at the inter- Orthot Int 198 1;5:23-28. and Orthotics, 2001.
face between residual limb and socket: 15. Br11nemark R, Bdlnemark Pl, Rydevik 18. Zahedi S: Bewertung und Bio-
The relationship between pressure B, et al: Osseointegration in skeletal mechanik der intelligenten Prothese:
reconstruction and rehabilitation: Eine Zwei-Jahres-Studie. Orthop Tech
A review. J Rehabil Res Dev 2001;38: 1995 ;46:32-40.
175-181.

•
. Management
Issues
Future Developments:
Osseo integration in Trans/einoral
Amputees
Kingsley Peter Robinson, MS, FRCS
Rickard Branemark, MD, MSc, PhD
Introduction
The possibility of attaching a prosthe- ued and all implants were removed. sistant to infection. Titanium forms a
sis directly to the bone of a residual Cutler and Blodgett2 also studied resistant surface oxide layer. In living
limb has long been anticipated. What skeletal attachments experimentally. tissue this can be augmented by a per-
was required was technology that en- In the United States, Mooney and oxide layer, which is thought to be a
abled bone to incorporate a foreig'1 associates 3 fitted a prosthesis to the hydrated titanjum peroxy matrix.
material and allowed the material to humerus of a triple amputee; because This layer does not tolerate surface
safely penetrate the e>..'ternal surface of of leakage, the implant was removed pathogenic activity, nor does it inhibit
the body. after a few months. Further study of endothelial cells or osteocytes. At the
The first application of metal pen- penetrating in1plants to attach pros- same time, however, it does inhibit
etration of both skin and bone was by theses in a dog model was conducted macrophages, thus allowing the mate-
Malgaigne in 1843, when he used an by Esslinger. 4 Hall and Rostoker5 re- rial to be tolerated in the living bone
external screw to engage a fractured ported a considerable degree of suc- without the interposition of a fibrous
tibia in an early form of external fixa - cess with implants into the hind limb tissue layer. This close contact has
tion. Since then, the Steinmann pin of Spanish goats; of 20, only two im- been termed osseoi11tegration with
has been used routinely to control plants failed over a period of 14 the implanted material. 13 Research
bone position by temporary transfix- months, during which time some of continues to investigate the benefit
ion of soft tissue and bone. Today, the goats were very active. Ling6 re- from s urface additives or treatment of
treatment by external fixation is well viewed the problems inherent in these the machined titanium surface. The
accepted. Over a long period of time, procedures. biomechanical effects of an in-
however, intraosseous foreign mate- These data provided Little encour- traosseous implant have been studied
rial may loosen and could remain an agement for further studies until an in California, Sweden, and the United
infection risk. Despite the extensive unrelated observation by Branemark7 Kingdom. 9 •ll, J 4 , 15 Jacobs and associ-
research and progress that has al- revealed the possibility of long-term ates 16 investigated the sensation de-
lowed prosthetic implants in bone to tolerance of a metal implant con- rived from the prosthesis in amputees
become part of routine orthopaedic nected to the exterior. To study mi- with conventional and bone-fixed
practice, this problem still exists. crocirculation within bone, Brane- prostheses. Nerve endings in proxim-
Experimental work on bone fixa- mark inserted a titanium observation ity to the intraosseous titanium im-
tion of limb prostheses in the past has tube into the bone marrow of rabbit plant and the role of neuropeptides
been sporadic and limited in scale. 1 A tibia. The device was almost impossi- were demonstrated in work by
project to develop this in the United ble to remove after several weeks of Ysander and associates. 17
States in 1942 was rejected. In 1946, study. The titanium appeared to have The interface between the skin and
Dll!nmer of Pineberg in Germany integrated with the bone, despite the the penetrating metal bas been the
studied implanted metal limb exten- transit through the skin and soft subject of a large number of studies.
sions in sheep and extended the study tissue. Acrylate adhesives provide only tem-
to human patients, four of whom had In later studies, Bdlnemark and porary attachment to a metal surface.
prostheses attached to metal im- others8 - 12 showed that commercially A considerable degree of cellular in-
plants. When infection developed in pure titanium was well tolerated vasion into mesh materials, including
one patient, the study was discontin- within living bone and relatively re- titanium gauze and textile meshes of

be changed without disturbing the pending on body weight and initial

implant. A damaged abutment can be bone quality.
replaced painlessly without anes-
thetic. If use of the system has to be Clinical Management
discontinued, only the abutment need Management of the transfemoral am-
be removed, after which the penetra- putee is in accordance with the guide-
tion site heals rapidly. lines of Malchau 20 for the stepwise
Figure 1 Titanium component s of t he
Branemark prosthetic attachment system. AU of the components facing the introduction of new implant technol-
The threaded implant is on the left; t he biologic environment are fabricated ogy. These guidelines have now been
skin-penetrating abutment is on t he from commercially pure titanium to used in Gothenburg, London, and
right, with the retaining screw below it. avoid electrolytic corrosion. For this Melbourne with minor variations.
(Courtesy of Rickard BrJnemark, MD,
reason, the stronger titanium alloys Amputees interested in the Brane-
MSc, PhD.)
are avoided in the system. The instru- mark system at present must appreci-
ments used to handle these compo- ate that the procedure remains in an
various polymers, has been observed, nents are also made of the same tita- early stage and must therefore be pre-
but these materials have not yet been nium. pared to be recruited as volunteers for
shown to provide any advantage over Time is required for the living participation in the clinical study.
the simple skin perforation of the bone to develop tolerance to the tita- They must sign an in-depth informed
Branemark method. One case of os- nium. At present this period is con- consent document that incorporates
seointegrated attachment of a pros- sidered to be 6 months in the residual the widest ethical considerations and
thesis in a male transfemoral amputee femur, 3 months in a digit, and Jess in is approved by the appropriate au-
was reported by Staubach and Grun- a dental implant. A two-stage surgical thorit ies.
dei. 18 They used titanium mesh and procedure is necessary to establish the Comprehensive information is
reported on surface treatment of the system in limb amputees. Dming the provided to each candidate in an ini-
titanium. first stage, the implant is placed in the tial pamphlet and during a prelimi-
bone, and the skin and soft tissues are nary clinic consultation, after which
closed. In the second stage, the scar the candidate's medical advisors are
The Branemark is reopened, the skin penetration consulted to obtain their approval
System for Bone formed, and the abutment placed, in and referral. Further consultation and
Attachment of Limb preparation for attachment of the discussion is undertaken to determine
training aid that precedes the use of if the patient should proceed to a 3-
Prostheses the limb prosthesis. te 5-day residential assessment. Dur-
The implant that is inserted into the The Branemark system has been ing this period each member of the
medullary cavity of the residual long used extensively for dental prostheses, multidisciplinary team can contrib-
bone after an amputation consists of maxillofacial reconstructions, pros- ute, and the amputee can obtain all
a tubular component with a surface thetic ears, and hearing aids. Pha- the available information on which to
self-tapping screw thread that engages langeal and metacarpal implants are base a decision to take part in the
the inner aspect of the cortex of the particularly effective for thumb pros- clinical study. The opportunity to
shaft of the bone (Figure 1). The con- theses. Radial and ulnar implants meet others using the system for the
necting component, called the abut- have been used for transradial ampu- same amputation level is an impor-
ment, is attached to the lower end of tees, and humeral implants for higher tant factor in establishing realistic ex-
the implant. The abutment penetrates levels. All of these amputees have pectations. In addition, because 18
the skin at the most distal part of the been treated by custom-designed im- months is such a lengthy time com-
residual limb and protrudes to permit plant systems. 19 mitment to a clinical program, the
the attachment of the prosthesis with In the lower limb, the most com- amputee must be confident that the
a screw-tightened clamp. mon use is for implants in the resid- benefit will justify participation. Out-
The abutment is located in the ual femur for transfemoral amputees, side employment may not be possible
lower end of the implant in a hexago- with the system available "off the during the training period after the
nal recess and is retained by a long shelf." The system is not yet available second-stage operation.
bolt that passes through the abutment for other lower limb levels. Because of Recruitment to the osseointegpted
to engage an internal threaded section the high loading imposed by lower prostheses study is intended to ex-
in the lower part of the implant. The limb prosthesis use, the load is slowly clude those amputees with factors that
head of the retaining bolt thus forms and progressively applied. The time interfere with bone healing, such as
the lowest point of the protruding from commencement of loading to steroid use, immtmosuppression, dia-
abutment when in place. This ar- unrestricted use of a prosthesis with- betes mellitus, chemotherapy medica-
rangement enables the abutment to out aids may be 6 to 12 months, de- tion, neoplastic disease, and age older
American Academy of Orthopaedic Surge(!nS

Chapter 53: Future Developments: Osseointegration in Transfemoral Amputees 675
Figure 2 A, Reamer guided by t he specially designed jig. B, Implant being introduced into the prepared medullary cavity of the femur.
than 70 years, as well as adverse factors the scan, and the axis must be main- Usually the existing terminal scar
such as heavy smoking, weight greater tained constantly at 90° to the plane of of the residual limb is excised and the
than 100 kg, or psychiatric disorders the scan cuts. Three-dimensional re- original full-thickness skin flaps are
that could interfere with maintenance construction may be helpful with de- raised. The muscle in the vicinity of
of the treatment protocol. formed or abnormal bones. The im- the bone end is cleared. The optimum
Local factors in the residual liml:, plant is placed where it has optimum length of the residual femur will al-
may also be adverse, such as osteope- contact with the compact cortical ready have been determined from ra-
nia, residual bone infection, and local bone of the femoral shaft; this location diographs; any necessary shortening
or general bone disease. Residual is where the self-tapping screw thread will be performed at this stage. Ide-
bone length that is too short to con- must engage to a depth of 1.5 mm over ally, space of at lea.st 25 cm will be
tain the implant, degenerative hip the maximum surface area of the im- available from the end of the femur to
joint disease, and fixed flexion defor- plant. The typical diameter in an adult the level of the opposite knee joint
mity of the hip are also contraindica- male amputee is 16 to 20 mm. line for the attachment of compo-
tions. The surgical preparation is the nents. The minimum length of resid-
The amputees who are likely to same as for any other major ortho- ual femur should be 5 to 8 cm below
benefit most are those who are unable paedic procedure in which a prosthesis the lesser trochanter. Bone graft to the
to tolerate a conventional socket pros- is implanted. Low-molecular-weight intertrochanteric bone might be indi-
thesis, either entirely or to the extent heparin prophylaxis is initiated, and cated where poor-quality cancellous
that the use of a prosthesis is limited perioperative intravenous antibiotics bone is present. The periosteum will
significantly. Individuals with short are administered. The patient's blood be stripped proximally to facilitate the
residual limbs and bilateral transfem- type should be known, and a transfu- necessary resection. Any required re-
oral amputees are good candidates. A sion capability should be available on- construction of the residual lin1b is
survey of transfemoral amputees in- site; however, transfusion is rarely re- normally delayed until the second-
dicates that many of them accept dis- quired. stage procedure.
comfort and poor function from their The bone end is exposed, the fem-
socket prostheses.2 1 As experience Surgical Procedure oral medullary cavity is identified, and
with the technique expands, indica- First-Stage Operation the muscles are split proximally to ex-
tions for the system may also grow. Either epidural or general anesthesia pose the femoral shaft 5 to 10 cm
is satisfactory. The patient should be proximal to the bone end. In this ex-
Preoperative Preparation in the prone position, with the resid- posed area, the clamp of the intro-
Prior to the first operation, the im- ual limb isolated and mobile. The op- ducer jig is applied, and a provisional
plant is selected or manufactured on erating room should be equipped alignment with the bone end is fixed
the basis of 1: I -scale CT scans of the with image intensifier capability. (Figure 2, A). Using the jig, the femoral
residual femur. The spiral CT scan on Mono- and bipolar diathermy are canal is entered and the alignment
skeletal setting is calibrated for 1-mm used, and saline irrigation with suc- checked with the image intensifier.
cuts over the length of the proposed tion is required. Free blood and bone With this alignment, the femoral med-
site of the implant and 3-rnm cuts over material are collected to provide lu- ullary cavity is bored out with hand
the remainder of the femur. The limb brication for insertion of the implant reamers to the diameter planned from
must be immobilized securely during and as a source of bone cells. the CT scan. Slow rotation and fre-

sue flaps to be raised. The estimated

site for the penetration of the abut-
ment would have been marked when
the formation of the flaps was
planned. The important consider-
ations are the need for healthy skin, a
blood supply uncompromised by pre-
vious scars, and a flap design that, if
possible, avoids excessive tissue sepa-
ration. The dissection is carried to the
Figure 4 The second-st age surgery, show- bone end and the closing screw is re-
ing the abutment penetrating the pre- vealed.
pared skin flap and connected to the im- If the first-stage operation did not
plant, which is within the femu r on the
produce an effective myoplasty or
right.
myodesis, this procedure must now be
performed to retain the function of
serve the internal thread, which later the residual muscles. Redundant soft
will accept the abutment-retaining tissue is trimmed and muscle is se-
bolt. The displaced muscle and soft curely sutured to the distal perios-
tissue are sutured into place, and the teum and the opposing muscle to ef-
Figure 3 Postoperative radiograph of t he
res idual femur with the implant in place. skin is closed with suction drainage in fect a strong myoplasty located at, but
Ideally, reaming should coincide with the place. A normal dressing is applied. not covering, the bone end. In some
top of the implant. The amputee usually makes a rapid early cases the muscles were secured
recovery. The residual limb is rested by sutures through multiple small
until the suction drain is removed at drill holes at the bone end (myode-
quent saline irrigation are used to
24 hours. At this time, when full ac- sis), but this impaired healing at the
avoid bone beating. The hazards of
tivity is resumed, most amputees who penetration site. The bone end should
bone damage from heating have been
have been unable to use a prosthesis be flat, smooth, and clear of perios-
described by Krause and associates. 22 teum, witl1 rounded edges to produce
will recommence crutch walking. A
The alignment is checked repeatedly the largest possible area of living bone
conventional prosthesis can be worn
until the implant is inserted. if this was possible before the opera- for adhesion to the skin at the pene-
Any bone residues and the filtrate tion. However, a supervised exercise tjation site.
of any blood collected are introduced program should be initiated promptly The position of the penetration
into the marrow cavity above the im- so tl1at a hip flexion contracture does mark is checked when the flap is
plant site. The implant is mounted on not develop. placed over the bone end. The inside
its introducer, whkh is placed in the In the 6 months until the second of the flap at this site is thinned over
guide used for the reaming process stage, maintaining a high level of an area corresponding to the bone
(Figure 2, B). The introducer acts as a physical fitness is encouraged. Weight end, in the manner of a full-thickness
shaft to drive the implant mounted gain must be avoided, and anything skin graft. This can be safely achieved
on its proximal end, powered by the that compromises bone healing is dis- by using the edge of a glass slide as a
"T" handle at the other end. Some couraged, including smoking, sub- scraper. The closing screw and cylin-
skill and strength are required to stance abuse, and excessive alcohol der are removed and the selected
screw the implant into its planned consumption. A normal varied diet abutment checked for size and fit.
position. If the rotation is stopped, with calcium and vitamin supple- Considerable cleansing and irrigation
the implant may bind, despite lubri- ments is recommended. During this are required to clear the lumen of the
cation with blood and saline. When period, radiographs and isotope scans lower portion of the implant. The
the implant is in place, the position is should be avoided if possible. penetration of the skin for the transit
checked again, and the image intensi- of the abutment is made with a single
fier images are recorded for future Second-Stage Operation stab incision or with a puncture by a
reference (Figme 3). The preoperative management is the dermatology biopsy punch. The abut·
The lumen pf the implant is thor- same as for the first-stage operation, ment is passed through the penetra·
oughly cleansed with saline irr.igation. with administration of antibiotic pro- tion in the skin flap and seated in the
The closing screw and stage-one tem- phylaxis and low-molecular-weight hexagonal socket at the lower end
porary cylinder are then inserted heparin. The previous surgical scar is of the implant (Figure 4). The
from below to close the lower part of excised or reopened to allow full- abutment-retaining bolt is then intro·
the lumen of the implant and pre- thickness skin and subcutaneous tis- duced into the lower end of the abut·

ment and advanced to engage the started. The prevention of hip flexion
threaded part of the lwnen of the im- contracture is of great importance.
plant. It is finger-tightened at this The patient is reviewed weekly until
stage, and the soft tissue is lightly su- the sixth postoperative week, when
tured to locate the flap without any the training program begins.
tension on the penetration site. The torque of the abutment-
The skin closure is accomplished retaining bolt is checked at regular in-
in a conventional fashion, with suc- tervals. Some tightening may be re-
tion drainage if required (a he- quired to regain the 12-N·m torque.
Figure 5 The healed residua l limb, with
matoma could compromise the via- Any loosening at the abutment-
th e abutment proj ecting from the pene-
bility of the skin at the penetration implant interface will cause micro- tration site.
site). The abutment bolt is tightened motion, with component wear and
to a torque value of 12 N·m, and its black discharge of titanium oxide par-
ticles. walking is possible. The amputee
security is once again checked. The
penetration site is dressed with paraf- A short training prosthesis is pro- learns to recognize that pain in the vi-
vided to facili tate the exercise pro- cinity of the implant represents over-
fin gauze, and the residual limb with a
gram and to apply measured force to loading and that this resolves quickly
fluffed gauze light-pressure bandage.
the abutment a11d thus to the im- with load reduction or rest. Persistent
A dressing cylinder is provided to fit
plant. The training prosthesis is a tu- pain must be investigated to exclude
on the stem of the abutment and re-
bular extension 35 to 40 cm long, the possibility of deep infection. Re·
tain the penetration dressing. This
which is clamped to the abutment. peated overstress pain will delay
10-cm-diameter cylinder is secured
This corresponds to the length of the progress, especially if the pain takes
by a slide to the abutment shaft; th~s
opposite femur, measured from the several weeks to resolve. This will de-
allows easy removal for dressing
opposite knee joint line. The prosthe- termine the time required until full
changes. The pressure exerted by the
sis has a platform end on which the weight bearing and activity can be
dressing must be monitored to avoid
amputee can apply measured vertical achieved. From our experience, we
skin necrosis of the penetration site
loads to the abutment, initially 20 kg, have found that the amputee should
over bone end.
by pressing onto spring bathroom be prepared for the loading program
After the operation, close supervi-
scales. The axial weight load is in- to take up to l year from the second-
sion is necessary to ensure rapid heal-
creased by IO kg each week. After stage operation, but usually it is
ing with adhesion of the skin to the
3 weeks, the load is applied for IO to achieved in 3 to 6 months.
bone end. Close approximation of the
15 minutes each day. When 40-kg
skin to the abutment shaft and stable Prosthetic Management
weight bearing is achieved, resisted
healing of the skin onto the bone end When the initial assessment is con-
exercise is commenced with a 1-kg
appear to provide the best chance of a weight attached to the end of the ducted, the amputee is asked to pro-
trouble-free penetration (Figure 5). vide h is or her latest lower limb pros-
short training prosthesis. The ampu-
Because daily hygiene is also critical, tee may then proceed to prone kneel- thesis, even if it has not been used for
the amputee is instructed in the care ing. Once 60-kg loading is achieved, some years. To assess gait, a dynamic
of the penetration. Each day the site upright kneeling can be initiated. By video recording is made of the ampu-
should be wiped with sterile saline so- 12 weeks, full weight bearing may be tee walki ng while wearing the pros-
lution and any crusting or discharge reached. If at any stage the residual thesis in the gait laboratory; force
removed. After the first week, no limb becomes painful, the loading plate gait studies are also conducted.
dressing is required; a polyethylene program is interrupted until the pain The knee mechanism is first replaced
foam disk or a twist of dry gauze is all has resolved. Full weight bea1·ing with the Swedish Total Knee (Ossm,
that is required. Ventilation and should be achieved 3 to 6 months af- Reykjavik, Iceland), which is the stan-
cleanliness are the only necessities. ter the second-stage operation. At this dard for the study. Records (including
time, the amputee can be supplied video) are then made of the ampu-
Postoperative with a full-length temporary prosthe- tee's gait in the preoperative state.
Management sis with a knee and foot mechanism. As described earlier, a short train-
The patient is discharged home 2 to Standing weight bearing is coming prostl1esis is provided after the
3 weeks after the second-stage opera- menced between parallel bars with a second-stage operation for loading of
tion, when the skin around the pene- progressive increase in load until the abutment before the first full-
tration is satisfactory and the tissue 6 weeks of partial weight bearing en- length training prosthesis is made.
reaction to the surgery has resolved. A ables the patient to start walking with This is a temporary endoskeletal
gentle exercise program that avoids crutches. The patient progresses to prosthesis, constructed from standard
resisted or rotational movements is walking with canes until unrestricted components with the exception of the

Figure 6 The prosthetic attachment system. A, The top clamp conceals the abutment and incorporates the Mark 1 fail-safe device,
above the universal knee mechanism attachment. B, The clamp re leased to show t he relationship t o the abutment . C, The later Mark 2
fai l-safe device (Rotasafe) provides protection against excessive rotational and bending forces in the event of accidental trauma.
securing clamp at the upper end. This devices to suit their individual re- muscles of the residual limb, in par-
screw-tightened clamp closes around quirements. ticular the hip adductors, and/or my-
the squared lower end of the abut- Below the knee mechanism, a stan- ostatic contracture of the abductor
ment. The screw is operated by an dard shank is connected to a Dynamic muscles will favor an abducted stance
Allen wrench, which is carried by the Foot (Otto Bock). The interposition with the prosthesis and a resulting
amputee. The clamp is incorporated of a torque control and shock- lurching gait. Amputees with well-
into an abutment protection device absorbing unit at ankle level has developed muscles walk with an al-
with a rotational fail-safe mechanism. proven to be of value. The character- most normal gait.
Below this is the alignment device for istics of the prosthetic heel and the A cosmetic cover can be supplied.
angular and axial adjustment. These compliance of the system are quite Caution must be exercised, however,
devices require a large range of move- obvious to the amputee, who will se- to avoid changes in the functional
ment and a high degree of security. lect the degree of shock absorption characteristics of the knee and ankle
Beneath this assembly is a standard that provides the maximum comfort mechanisms.
adaptor for attachment of the knee during and after walking activities. The most salient problem with the
joint mechanism. The length of the The degree of comfort appears to be prosthesis is protection of the implant
residual limb must allow a minimum strongly related to the accuracy of the al\d abutment from abnormal stress
distance of 25 cm for these compo- alignment and the way in which it is and trauma. Although the implant
nents. matched to tbe i11dividual's gait pat- within the femur is largely protected,
The basic knee mechanism for the tern. This seems to be more critica l in the femur could fracture above the im-
clinical trial, the Swedish Total Knee, amputees with bone-fixed prostheses plant. Fracture or bending of the abut-
allows 160° of flex.ion and has a me- than in those with a conventional ment and its retaining bolt are more
chanical stance-phase control; a hy- socket that provides a degree of com- likely. The damaged abutment can be
draulic swing-phase control is an al- pliance and tolerance. removed and replaced by unscrewing
ternative. When the amputee is able to The implant and abutment are in the bolt and extracting the abutment
assess the qualities of the knee mech- line with the femoral shaft, which an- under sterile conditions. This proce-
anism, other units are offered to meet atomically meets the ax.is of the lower dure is best performed in a minor op-
individual preferences. Some have pre- leg at 7° of valgus. However, if this an- erating room; however, no anesthesia
ferred the Otto Bock 3R80 mechanism gulation is incorporated into the is required. The penetration and the
(Otto Bock HealthCare, Vienna, Aus- alignment, it is poorly tolerated, and screw thread are carefully cleansed
tria), which allows 140° of knee flexion the gait remains abnormal with a lat- with saline before the new abutment
with both hydraulic swing-phase con- eral movement in each step. Currently and bolt are inserted. When correctly
trol and stance-phase control. Without the alignment is set by a process of seated, tl1e bolt is set to the correct
a socket, the full range of knee flex.ion trial and adjustment, to produce the torque of 12 N·m and the prosthesis is
is possible. This. has great value to the best gait for the individual amputee. t hen reattached.
osseointegration project amputees be- The gait is satisfactory for the indi- Because this is a costly and tro uble-
cause they are able to pedal a cycle vidual yet appears abnormal to an ob- some complication, incorporation of a
without difficulty and can squat or sit server. Although not required by the fail-safe device in the prosthetic sys-
cross-legged on the grow1d. Amputees amputee, use of a cane will improve tem is desirable (Figure 6). This device
also have the opportunity to try other the gait. A general weakness in the should be immediately below the
American Acade,riy of Orthopaedic Surgeons

abutment clamp at the upper end of hand. Radial and ulnar implants
the prosthesis to protect against exces- transmit pronation and supination to
sive rotational and angulation stress. the prosthesis, and the stability of the
One sophisticated and complex com- prosthesis allows precise myoelectric
ponent is available, the Rotasafe device control of hand function. Humeral
(Integrum AB, Gothenburg, Sweden), implants also enhance arm prosthetic
which can be placed between the function. Although these have been
clamp and the knee mechanism. This uJ1der progressive development since
device can be set to release when 1991, the number of users remains
stressed to a predetermined value. It small. Branemark and associates 19 re-
will then stabilfae to prevent uncon- viewed these various aspects of os-
trolled collapse or detachment of the seointegration in 2001.
prosthesis. The first application of lower limb
The prosthetic system gives the implants was in a bilateral transfemo-
amputee a fee(jng of security. In addi- ral amputee with short residual limbs
tion, because the prosthesis is at- who was unable to wear prostheses
tached to the body, the amputee will and was limited to wheelchair mobil-
experience some sensory feedback ity. Her implants show no change after
from ground contact, enabling recog- 11 years. In the early part of the series,
nition of differences in the walking while the procedure and instrumenta-
surface. Termed osseoperception, this
phenomenon has been studied in re-
lation to the awareness of vibration!
tion were being developed, the im-
plants were performed on an individ-
ual volunteer basis. The design of the
I
Some patients comment that the implant was then refined, the surgical
prosthesis feels like a part of them; as procedure modified, the abutment im- Figure 7 One of the London amputees
a result, they feel more normal. The proved, and the duration of the heal- during a prosthetic review 2 years after
prosthesis is worn without time Limi- ing phase and the loading program al- the second-stage operation.
tation and incorporated into a nor- tered. Because of all these changes, it
mal lifestyle. Opportunities to partic- was difficult to choose a starting point
ipate in sporting activities expand, for the collection of clinical evidence from eight amputees. In two of them,
including cycling and swimming in to evaluate the procedure. A formal the implant was later replaced, with
clean water. The ability to perform cli nical trial for lower limb amputees satisfactory results. One amputee fell,
manual labor, drive vehicles, and op- called Osseointegration Prosthesis Re- fracturing the femur, but went on to
erate machinery has enabled return to habilitation for Amputees began in full recovery. Several required abut-
employment in the British group. May 1999. Although 50 lower limb ment replacement because of damage
Swedish amputees have returned to amputees have undergone the proce- from falls; these incidents preceded in-
farming and animal husbandry. The dure, only 16 have been formally en- troduction of the Rotasafe device.
prosthesis can be attached and re- roUed in the research trial. 23 The trial The Melbourne experience in-
moved readily with the Allen wrench, was extended to London and Mel- cludes two transfemoral amputees
and fulJ hip and knee flex:ion yields an bourne, in addition to the Swedish who have used the system for 2 years.
increase in agility. subjects. The male amputee had one abutment
The Swedish lower limb amputees change, and the female amputee has
Clinical Application include three at transtibial level, two had no problems.
The clinical application of the os- with very short residual limbs. These The London experience is of 11
seointegration technique in amputees procedures failed as a result of poor male amputees, aged 25 to 41 years.
followed the experimental work in bone quality at the site, with resulting The longest period of use is 6.3 years
Gothenburg, after considerable expe- lack of stability. The third transtibial (cumulative use, 33 years). Two am-
rience had been acquired in the use of amputee had a long residual limb (27 putees had the implant removed be-
implants for dental restoration and cm from the tip of the greater tro- cause of deep infection; one may have
maxillofacial reconstructions. The ap- chanter) and has successfully used the been a recurrence of a past infection.
plication was extended to digital, system for more than 5 years. The Both now have satisfactory socket
metacarpal, and arm implants for other trial participants were all at the prostheses. The remaining nine am-
prosthetic attachment. Thumb pros- transfemoral level. Some episodes of putees are all effective prosthesis users
theses mounted on metacarpal im- minor superficial infection occurred, with active lifestyles; one is undergo-
plants are particularly successful in and deep infection or loosening neces- ing job retraining, and the rest have
restoring function to the damaged sitated the removal of the implant returned to employment (Figure 7).

Superficial infections at the pene- ity and improved function for upper prosthetic fitting. Bull Prosthet Res
tration site, which have been infre- limb prostheses and a valuable re- 1970; l 0:219-225.
quent, have been treated initially with placement for a missing thumb, appli- 5. Hall WC, Rostoker W: Permanently
amoxyl and flucloxacillin replaced as cation in the lower limb offers the op- attached artificial limbs. Bull Prosthet
indicated by the microbiology swab portunity for full prosthetic use to Res 1980;17:98-100.
culture result. However, the active life- transfemoral amputees who have 6. Ling RS: Observations on the fixation
styles enjoyed by the group have re- been unable to achieve rehabilitation of implants to the bony skeleton. Clin
sulted in the replacement of 11 abut- and walking function with a conven- Ort~op 1986;2 l 0:80-96.
ments. In one patient the appearance tional socket prosthesis. In the future, 7. Branemark Pl: Vital microscopy of
of black discharge indicated some mi- osseointegration may play a role in bone marrow in rabbit. Scand J Clin
cromotion in the titanium attach- forequarter and transpelvic amputa- Lab Invest 1959;11 (suppl 38): 1-82.
ment of the abutment. This was not tions as well as transtibial amputa- 8. Branemark PI: Osseointegration and
controlled by maintaining the speci- tions. Perhaps one day the technique its experimental background.
fied torque, and a customized new will have developed to the point J Prosthet Dent I 983;50:399-410.
abutment solved the problem. where it could be used as a primary 9. Branemark Pl, Rydevik BL, Skalak R:
The groups were assessed by a clin- treatment. Osseointegration in Skeletal Reconstruc-
tion and Joint Replacement. Chicago,
ical psychologist both by interview
IL, Quintessence Publishing, 1997.
and questionnaire. The positive find-
ings were enjoyment of increased ac-
Acknowledgments 10. Albrektsson T, Branemark PI, Hansson
HA, Lindstrom J: Osseointegrated
tivity, greater mobility, and a more We wish to acknowledge the contribu-
titanium implants: Requirements for
normal lifestyle. Several commented tion made to this work by the multi-
ensuring a long-lasting direct bone-to-
that they no longer felt disabled by disciplinary teams of the Orthopaedic implant anchorage in man. Acta
their amputation. The quick and easy Departments and Rehabilitation Ser- Orthop Scand 1981;52: 155-170.
connection and removal of the pros- vices in Gothenburg and Kingston 11. Branemark RA: A Biomechanical Study
thesis were appreciated, together with Hospital with the Rehabilitation Cen- ofOsseointegration: In-vivo Measure-
the sensory awareness of the type of tre of Queen Mary's Hospital, Roe- ments in Rat, Rabbit, Dog and Man.
ground contact. The appearance of hampton, London. We are grateful for Gothenburg, Sweden, Gothenburg
the abutment was accepted by close the support of ilie Institute of Applied University. 1996. Dissertation.
family, and a cosmetic cover was not Biotechnology, the University of 12. Hansson HA, Albrektsson T, Bdlne-
always requested. Pain was an issue Goilienburg, the University of Suney, mark PI: Structural aspects of the in-
only after severe overload or trauma the Douglas Bader Foundation, ilie terface between tissue and titanium
and cleared spontaneously. Pain that Remedi Foundation, and the Norman , implants. J Prosthet Dent 1983;50:
Rowe Trust. 108-113.
did not clear could be an indication
of a deep infection. 13. Linder L, Albrektsson T, Branemark,
Pl, et al: Electron microscopic analysis
The primary negative aspect that References of the bone-titanium interface. Acta
emerged was the long period of com-
1. Murphy EF: History and philosophy of Orthop Scand l 983;54:45-52.
mitment to the program, with the
attachment of prostheses to the 14. Skalak R: Biomedical considerations
attendant domestic, social, and em-
musculo-skeletal system and of pas- in osseointegration prostheses.
ployment problems. The previously sage through the skin with inert mate- JProsthet Dent 1983;49:843-848.
healthy amputees fow1d it difficult to rials. J Biomed Mater Res 1973;7: 15. Xu W, Crocombe AD, Hughes SC: Fi-
assume the role of patient; involve- 275-295. nite element analysis of bone stress
ment with the hospital included fre- 2. Cutler E, Blodgett JB: Skeletal attach- and strain around a distal osseointe-
quent supervision and adjustments. ment of prostheses for the leg (final grated implant for prosthetic lim b
The hygiene requirements were only report of Harvard University). Con- attachment. Proc Inst Mech Eng2000;
slightly inconven ient. All amputees felt tract OEM cmr-214. Washington, DC, 214:595-602.
that the advantages outweighed the 1945, Committee on Medical Research 16. Jacobs R, Bra.nemark R, Olmarker K,
disadvantages, however. of the Office of Scientific Research and Rydevik B, Van Steenberghe D, Brane-
Development. mark PI: Evaluation of the psycho-
3. Mooney V, Predecki PK, Renning J, physical detection threshold level for
Summary and Gray J: Skeletal extension of limb vibrotactile and pressure stimulation
Conclusions prosthetics attachment problems in of prosthetic limbs using bone an-
tissue reaction. J Mater Res Symp 1971; chorage or soft tissue support. Prosthet
Osseointegration provides a new and 2:143-159. Orthot Int 2000;24:133-142.
original method for the direct attach- 4. Esslinger JO: A basic study in semi- 17. Ysander M, Branemark R, Olmarker
ment of prostheses to the skeleton. buried implants and osseous attach- K, Myers RR: Intramedullary osseo-
Although the concept provides stabil- ments for application to amputation integration: Development of a rodent

model and study of histology and neu- A review. J Rehabil Res Dev 2001;38: 22. Krause WR, Bradbury DW, Kelly JE,
ropeptide changes around titanium 175-181. Lunceford EM: Temperature eleva-
implants. J Rehab Res Dev 2001;38: 20. Malchau H: On the Importance of Step- tions in orthopaedic cutting opera-
183- 190. wise Introduction ofNew Hip Implant tions. J Biomech 1982; ) 5:267-275.
18. Staubach KH, Grundei H: The fust Technology. Gothenburg, Sweden, 23. Gunterberg B, Bdlnemark PI, Brane-
Gothenburg University, 1995. Thesis. mark R, Bergh P, Rydevik B: Osseo-
osseointegrated percutaneous prosthe-
integrated prostheses in lower limb
sis anchor for above-knee amputees. 21. Hagberg K, Branemark R: Conse-
amputation. Proceedings of IXth World
Biomed Tech 2001;46:355-361. quences of non-vascular trans-femoral
Congress of the International Society for
19. Branemark R, Branemark Pl, Rydevik amputations: A survey of quality of Prosthetics and Orthotics. Amsterdam,
B, Myers RR: Osseointegration in skel- life, prosthetic use and problems. The Netherlands, 1998, pp 137-139.
etal reconstruction and rehabilitation: Prosthet Orthot Int 2001;25:186-194.

•
Musculoskeletal Complications
.
John J. Murnaghan, MD, MSc, MA, FRCSC
John H. Bowker, MD
Introduction
One of the primary aims of any surgi- sure early identification and timely during prosthesis use (Figure 1). By
cal procedure, apart from obtaining management of complications. using atraumatic technique during
rapid, sound wound healing, is the skin closure, the surgeon can to a
prevention of surgical complications. large extent avoid producing local is-
Amputation has the additional possi~
Early Complications chemic areas. Such techniques include
bility of complications related, to the Delayed Wound Healing using widely spaced, simple sutures
residual limb-prosthesis interface. In Delayed wound healing can result placed in well-everted skin edges and
general, the frequency and severity of from marginal necrosis, infection, supplementing them with paper su-
complications associated with ampu- malnutrition, or direct trauma to the
tations can be minimized if the sur- residual limb from falls . These factors
geon is interested in the cha.Uenge of may be present alone or in various
accomplishing a properly designed combinations. Delayed wound heal-
and executed amputation and keeps ing is reported to affect from 19% to
abreast of innovations. A casual or 40% of transtibial amputations. 1•2
defeatist attitude toward amputation Careful preoperative assessment of
surgery as a treatment modality may transcutaneous oxygen tension (> 20
contribute to many of the problems to 30 mm Hg) and Doppler pressures
discussed in this chapter. (ankle-brachia! index > 0.5), com-
Musculoskeletal complications in bined with a comprehensive clinical
amputees can occur early (within assessment, should identify the ap-
days or weeks postoperatively) or late propriate biologic level for amputa-
(months or years after amputation). tion that would result in a greater
Early complications include delayed than 75% probability of healing.3 The
wound healing, limb-fitting problems correct rehabilitation-related level for
related to residual limb shape, joint the amputation is affected by other
tlexion contractures, and impaired factors as well, discussed in the chap-
motor control of the residual limb. ters on particular amputation levels.
Late complications include painful
bursitis, chronic sinus formation, Marginal Necrosis
pain, adherent scar, damage to insen - Wound necrosis may be due to sub-
Figure 1 Lateral radiograph of a trans-
sate skin, volume changes, and bony optimal surgical technique. In an at- t ibial amputation shows inappropriate
spurs. In addition, several regional tempt to save length, surgeons some- beveling of the tibia and f ibula. The
phenomena are associated with lower times retain marginal_ly viable tissue. chisel-shaped t ibia caused severe pain on
and upper limb amputations. Opti- Such tissues must be handled and re- attempted weight bearing while wearing
t he prosthesis. The tibial bevel should be
mal management of musculoskeletal tracted gently, using the hands rather
confined to the anterior cortex. A postero-
complications requires the knowledge than instruments whenever possible. lateral f ibular bevel conforms to the
and skills of the entire rehabilitation The bone should be beveled appro- shape of t he socket, avoiding a painful
team. Systematic follow-up will en- priately to prevent soft-tissue injury bony prominence.

684 Section IV: Management Issues
3 5 6 8 9 10 I
?
Figure 2 Transtibial amputation closed Figure 4 A, Marginal wound necrosis overlying the distal tibia. B, An elliptical area of
with minimal tension. Note the widely necrotic skin was excised, and 2 cm of the tibia and fibula was resected to allow primary
spaced simple skin sutures reinforced closure without tension.
with adhesive paper strips.
overall condition of the patient. Mc- sure. 5 If debridement reveals deep ne-
Collough4 recommends revision if the crosis, the dead tissue should be
band of necrosis extends more than resected, followed by a trial of dress-
1.2 cm from the wound edge. Treat- ings for 7 to 10 days. Occasionally the
Joint line able conditions such as malnutrition necrosis may continue to extend de-
should be addressed by caloric and spite wound debridement, warranting
nutritional supplementation. Under- revision to a more proximal level. Of-
lying medical conditions (eg, diabetes ten this revision can be done within
mellitus or renal failure) should be the same limb segment, but some-
managed to the extent possible. If the times amputation at the next proxi-
surgeon decides to proceed with revi- mal level is reg uired.
sion, the choices are local wound revi- Rigid, semirigid, or soft postopera-
sion in the same limb segment or re- tive dressings can be used for trans-
Figure 3 The likelihood of a rev1s1on is vision to the next more proximal tibial amputations. The benefits of a
high when delayed healing or marginal level. rigid or semirigid postoperative
necrosis occurs in the shaded area overly- In lower limb amputations, the lo- ~ressing include support for the pos-
ing the tibia, especially distally. (Adapted cation of the wound necrosis relative terior soft tissues (thereby diminish-
with permission from Sunnybrook Centre
for Independent Living, Toronto, Can-
to the tibia is a key consideration ing tension across the wound), con-
ada.) (Figure 3). Small areas of marginal trol of edema, and reduction in pain
wound necrosis not overlying the dis- during postural repositioning. In ad-
tal tibia can be locally debrided and dition, a rigid dressing protects the
ture strips (Figure 2) . In addition, the allowed to close by secondary inten- wound from direct trauma such as
use of mattress sutures, staples, and tion. If the area of necrosis overlies might be sustained from a fall and
forceps on the skin should be the distal tibia, however, shortening of also prevents knee Hexion contrac-
avoided. Subcutaneous sutures are the bone is required (Figure 4) . If this ture. Every possible method should be
rarely necessary if a good myofascial central area of necrosis is not reused to minimize the risk of falling in
closure has been obtained. Removal sected, the soft tissues frequently ad- this patient population.
of skin sutures should be delayed un- here to bone and are either painful
til wound healing has progressed well with weight bearing or tend to break Infection
( usually 3 to 4 weeks). This is espe- down later because of tension from Another cause of delayed wound
cially important in nutritionally de- shear forces. The surgeon should con- healing is infection, which affects ap-
pleted or immunocompromised pa- sider a local revision in this situation. proximately 16% of transtibial ampu-
tients. tation wounds. 4 Treatment includes
If wound n~crosis occurs, the prin- Trauma debridement, irrigation, dressings,
cipal decision relates to the timing Amputation wounds that have de- and antibiotics. Closme techniques
and extent of revision surgery. In hisced because of trauma and have can be selected after the infection has
turn, this depends on the location, minimal evidence of infection can been controlled. Techniques include
depth, and extent of the necrosis, as usually be treated with thorough exci- delayed primary closure, healing by
well as the health of the limb and sional debridement and prin1ary do- secondary intention, skin grafting, or

Chapter 54: Musculoskeletal Complications 685
Figure 6 Short left transtibial amputa-

tion with excessive, unstable soft tissue;
large "dog ears"; prominent distal tibia;
and d istal scar placement. Frequent
socket changes over several months were
required to improve the contour of the
Figure 5 A, An 87-year-old woman with severe vascular compromise sustained major de- residual limb and achieve definitive fit-
hiscence from a direct fall onto the end of a transtibial amputation wound. B, The re- ting. In contrast, the amputation of the
sidual limb 4 months after immediate closure with myoplasty. Healing was enhanced by right limb has a well-tailored posterior
a series of 11 hyberbaric oxygen sessions starting on the day of closure. The woman be- myofasciocutaneous flap, stabilized by
came a successful household ambulator with a prosthesis. gastrocnemius myodesis .
•
revision to a more proximal level. De- for surgical treatment. Two recent re-
layed primary closure may work if views indicate equivocal benefits.8•9
healthy granulation tissue is present One clinical report of 56 problem
7 to 10 days after debridement. lower extremity wounds found that
Although healing by secondary inten- none of the patients experienced
tion is excellent in theory, it often complete healing. 10 The potential role
creates a significant delay (2 to of hyperbaric oxygen therapy in pro-
6 months) in all other aspects of the moting healing after adequate surgi-
patient's rehabilitation, especially if cal treatment can be evaluated before Figure 7 Transtibial amputation with
the affected area is large. This is not a revision. Baseline transcutaneous ox- grossly excessive soft-tissue envelope. The
useful technique if necrosis overlies ygen measurements, with the subject amputee had poor rotational control of
the distal tibia because the soft tissues breathing room air, are taken on skin the prosthesis because of an ·unstable
just proximal to the area of necrosis. skin-socket interface.
usually adhere to underlying bone
and become painful or break \ down If values are less than 30 mm Hg, the
with subsequent weight bering. measurements should be repeated af- Residual Limb Shaping
Split-thickness skin grafting may sig- ter inhalation of 100% oxygen by
Surgical Techniques
nificantly shorten the healing time of mask for 15 to 20 minutes. If these
a debrided wound, but the surgeon values exceed 30 mm Hg, postopera- A great deal can be done during sur-
must be very selective in applying this tive hyperbaric oxygen treatment may gery to create a residual limb that
technique. Skin grafts do not hold up be beneficial. T his approach may al- readily accepts prosthetic fitting. The
well to the tension or shear forces of low preservation of the knee joint in ideal tapered shape results from a
weight bearing over subcutaneous selected cases (Figure 5). prope·r balance between skeletal and
bone, particularly in adults. 6 Surgical soft-tissue elements. To achieve this,
revision to a more proximal level may Malnutrition care must be taken to avoid redun-
result in the best tissue coverage. Preoperative screening for malnutri- dant soft tissue and corner flaps (dog
Ancillary treatments such as hy- tion should include determination of ears) (Figure 6). Floppy soft tissues
perbaric oxygen therapy have been the serum albumin level as an indica- are slow to shrink and can interfere
advocated for healing of chronic ul- tor of wound healing potential. Levels with optimal prosthetic gait because
cers and marginal necrosis of ampu- greater than 3.0 to 3.5 g/dL have been of an unstable skin-socket interface
tation wounds. Although some re- shown to correlate well with heal- that causes poor rotational control of
ports7 support its use, we have found ing. 11'12 Lower levels should be cor- the prostl1esis (Figure 7). Excessive
that hyperbaric oxygen treatments rected aggressively perioperatively tension in wound closure, which can
have not obviated the ultimate need with oral hyperalimentation. result from a disproportion between

Figure 9 Lateral view of a long transtib-

Figure 8 Myodesis in which the posterior ial amputation done w ith myoplasty
myofascia and the anterior and posterior alone. After a few years, the distal tibia
investing fasciae are sutured to the tibia became subcutaneous because of myo-
through drill holes on either side of an static contracture of the triceps surae. To Figure 10 Right Syme ankle disarticula-
anterior cortical bevel. The lateral muscu- correct painful local pressure and prevent tion with f ixed media l shift of heel pad.
lature is closed by myoplasty. ulceration, 3 cm of bone was removed, Reduction requ ired removal of 1.5 cm of
and the soleus was myodesed to the t he distal ends of the tibia and fibul a and
tibia. elliptical resection of medial scar tissue.
bone length and flap length, must also There was no contracture of the triceps
be avoided. Careful design of the skin surae or posterior t ibial muscles in t his
incision, trimming of the muscle flap, dius. Myodesis of the quadriceps to case.
the posterior femur provides excellent
correct relative bone length, myode-
sis, and elimination of redundant skin distal padding. The gluteus maximus,(
through its iliotibial band insertion, swelling decreases, the rigid dressing
will alJ contribute to a good initial may slip distalJy and produce local
and the hamstrings are reattached by
shape of the residual limb. pressure on the skin or circw11feren-
myoplasty, restoring strong hip exten-
To further ensure an optimal con- tial constriction with choking. The
sion. Firm attachment of all these
figuration, proper shaping of the cast should be changed at least weekly
muscles is of particular importance
bone end and soft tissues is also very and even sooner if there are any signs
for patients who are candidates for a
important. In a large series of trans- of loosening, foul odor, increased
prosthesis.
femoral revisions fo r World War II pain, or fever.
Myodesis without suture to bone
veterans, Dederich 13 was among the ' In amputations performed for ma-
can be effective in short to midlength
first to demonstrate the value of sta- lignancy that must be treated with
transtibial amputations where the fas-
bilizing the soft tissues by suturing cia of the triceps surae is firmly su- postoperative chemotherapy, nonab-
agonists to antagonists over the end tured to the deep fascia/periosteum of sorbable sutures should be used to
of the bone in a baJanced, physiologi- the anterior tibia. This provides ade- appose the fasciae and other deep
cally tensioned manner. The benefits quate soft-tissue stability and padding structures to minimize their tendency
included improved circulation and to the distal end. In long transtibial to retract in the presence of chemo-
decreased pain, allowing the patients amputations, however, myodesis of therapeutic drugs. These drugs may
their first comfortable prosthetic fit- the soleus directly to bone may be also delay skin healing, so in these
ting. If this construct becomes too preferred because myostatic contrac- cases it is advisable to leave sutures in
mobile, however, a distal bursa with ture of the triceps surae may leave the place for 3 to 4 weeks.
painful crepitance may form. The distal tibia in a subcutaneous position Syme ankle disarticulation pre-
most structurally stable residual limb, if periosteal myodesis alone is used sents unique surgical issues. If the
therefore, is achieved with myodesis (Figure 9) . heel pad is secure and well centered,
in which the surrounding muscles the patient will be able to tolerate a
and their fasciae are sutured directly Postoperative Management great deal of end bearing. If, however,
to bone through drill holes or firmly Following amputation, the residual the heel pad is not properly anchored
to periosteum (Figure 8) . The advan- limb often swells. Control of this to tl1e distal end of the tibia and/or
tages of adduc~or magnus myodesis swelling will reduce the tendency for the socket is loose, the heel pad rnay
for transfemoral amputation, as de- wound complications. Rigid or com- migrate posteriorly or to one side in
scribed by Gottschalk, 14 include stabi- pressive postoperative dressings of the prosthetic socket (Figure 10). If
lization of the femur in adduction, plaster or fiberglass or a combination the heel pad can be repositioned pas-
which enhances the function of the of plaster and flannel are effective in sively, it can be held with a carefully
physiologically tensioned gluteus me- limiting swelling. As the postoperative fitted prosthesis. If the heel pad be-

comes fixed by contracture or scar

and cannot be passively positioned, it
should be surgically repositioned by
division of the contracted tissue, in-
cluding the Achilles tendon, and re-
moval of a horizontal ellipse of excess
skin opposite the contracture, includ-
ing that portion of the surgical scar. It
may be necessary to remove a wafer of
distal tibia and fibula to allow proper
positioning of the heel pad. The plan-
tar fascia of the heel pad may then be
firmly sutured to the distal anterior
portion of the tibia and fibula with
drill holes.
Vascular surgery scars provide a
distinct challenge to the surgeon and
the prosthetist (Figure 11 ). Lower ab- Figure 11 Scar from prior vascular sur-
dominal and inguinal scars can be ir- gery crosses t he left inguinal crease and
ritated by the socket, and surface de- causes discomfort from the anterior
socket bri m and difficulty in achieving Figure 12 Elastic shrinker sock used to
pressions in the residual limb from shape a transtibial residual limb. Some
suction suspension.
scar contracture can create difficullJ7 patients experience significa nt pain relief
in achieving suction suspension. with a shrinker sock because of the con-
Traditionally, shrinking and shap- tact pressure against t he limb. Note the
breaks every few hours as needed for
tucks that were sewn in the sock as vol-
ing of the residual limb have been comfort, bathing, and skin care. Two ume red uction occurred over several
achieved by repeated application of socks should be supplied so that a weeks.
elastic bandages. Less than expert ap- clean one can be worn each day.
plication of these bandages can pro- Decrease in residual limb volume
duce a poorly shaped residual limb mediate postoperative prosthesis. Be-
is caused by loss of edema fluid as
with distal edema. The bandages cause this requires frequent wound
well as muscle atrophy. The most
should be applied on the bias with checks, it may be impractical in many
rapid decrease in volume occurs dur-
gradually decreasing pressure as the situations.
ing the first 6 weeks of prosthesis use.
wrapping proceeds proximally. Be- T his process may continue at a slower
cause layers of bandage tend to shift Joint Contractures
pace for up to 1 year. When a defmite
with movement, frequent rewrapping Joint contractures can significantly
plateau in shrinkage has been
is necessary to avoid circumferential affect prosthesis fit and function. It is
reached, as indicated by no further important to recognize any contrac-
constriction and distal edema. As a
need for shrinker sock tightening or tures preoperatively (Figure 13). If a
result, many surgeons and prosthe-
by stable weekly circumferential mea- patient with a significant knee flex.ion
tists now recommend the use of an
surements, a definitive prosthesis may or extension contracture is definitely
elastic shrinker sock. The sock is easy
be fitted. The attained volume can be not a prosthetic candidate, a knee dis-
to don and doff and provides a
maintained by applying the snug articulation or transfemoral amputa-
proper pressure gradient from distal
to proximal. The shrinker sock should shrinker sock everymght and when- tion should be the primary procedure
be snug when first fitted. A tuck may ever the prosthesis is removed during even if a transtibial level is achievable.
be sewn in the sides of the sock every the day. (Figure 14). On the other hand, if the
7 to 14 days to keep the fit snug as the The residual limb of a very muscu- patient is a possible prosthetic candi-
limb decreases in volume (Figure 12). lar or obese amputee may show little date, a concerted effort should be
Depending on limb shape and activity or no change in volume when an elas- made perioperatively to minimize the
level, the sock may need to be fitted tic wrap or shrinker sock is used. In contracture by stretching, splinting,
with a waist belt to keep it in place. To these cases, a temporary prosthesis and quadriceps strengthening.
prevent distal edema, the patient should be fitted as soon as the wound
must keep the end of the sock firmly is strong enough to tolerate weight Transtibial Level
against the end of the residual limb by bearing. This will cause the calf or Various techniques can be used to
pulling it proximally as often as re- thigh muscles to shrink most rapidly. avoid postoperative knee flexion con-
quired throughout the day. The sock The technique can also be used rou- tractw-es in transtibial amputees, in-
is worn continuously except for short tinely after amputation, with an im- cluding a rigid dressing (cast), semi-

Figure 13 Knee ' extension contracture in

a young woman fol lowing traumatic Figure 14 Bed-bound nursing home resi -
transtibial amputation and open femoral dent with dementia who has gangrene of Figure 15 Semirigid dressings can be
fracture. The femur healed with scarring the right foot and a severe knee flexion used following transtibial amputation. A
of the quadriceps to the fracture site. The contracture. A knee disarticulation, as posterior slab is applied over a well-
contracture did not improve w ith done on the left side, was the best and padded dressing with the knee in full ex-
3 months of therapy. At the time of knee safest solution for the patient. tension and then left in place for 3 to
disarticulation, dense scarring was found 5 days before wound inspection. A re-
throughout the knee joint. movable backslab is t hen used until the
ure 16). A circumferential rigid dress- patient regains fu ll quadriceps strength.
ing (cast) with the knee in full
rigid dressing, and knee immobilizer.
extension is recommended w1til the
Lightweight casts are effective but can
wound heals sufficiently to allow the
cause pressure sores over the patella if
removal of sutures. This is replaced
adequate padding is not applied. A
weekly for 3 weeks with full, active-
semirigid dressing consists of a pad-
assisted range of knee motion be-
ded backslab placed from the proxi-
tween cast applications. Care must be
mal thigh over the end of the residual
limb, coming anteriorly to the level of taken to adequately pad the thin skin
the tibial tubercle. This is wrapped over the tibial crest, tibial tubercle,
snugly with flannel, holding the knee and patella to prevent pressure necro-
in full extension (Figure 15). The sis. Pillows should not be placed un- Figure 16 A knee f lexion contracture oc-
dressing is left in place for 3 to 5 days der tl,e casted limb because this can curred postoperatively in a patient not
and changed in the clinic. If the pa- contribute to hip flexion contracture. treated with a rigid or semirigid dressing
Patients should also be encouraged to fo llowing transtibial amputation.
tient does not have a quadriceps lag, a
removable backslab can be used. lie prone and actively extend the hips
Limb supports should be used until two or three times a day to minimize prosthesis with the foot in slight plan-
full active knee extension is regained. this risk. tar flexion (equinus) to provide a
Amputee boards are supplied to pa- Severe knee flexion contractures knee extension moment on forefoot
tients using wheelchairs in the early are virtually impossible to eliminate contact. Consideration should be
postoperative period to support the once they become fixed . The dysvas- given to hamstring and capsular re-
knee and residual limb while seated. cular patient witl, a short, contracted lease for contractions in limbs that
Because they are difficult to fit accu- residual limb may require fitting with are not dysvascular.
rately, knee immobilizers are probably a bent-knee prosthesis, which is func -
the least effective means of preventing tionally no better and cosmetically in- Partial Foot Amputations
knee flexion contractures. ferior to that used for a knee disartic- Patients with partial foot amputations
Transtibial amputees with a short ulation (Figure 17). Occasionally, a between the transmetatarsaJ and
tibial segment are very likely to de- moderate knee flexion contracture Syme ankle disarticulation leveJs are
velop knee flexion contractures (Fig- may be improved by aligning tl,e likely to develop a plantar flexed

Figure 17 An amputee with severe knee I A

flexion contracture fitted with a "bent-
knee" prosthesis that functions as a knee Figure 18 A, Left transfemoral amputee w ith abduction contracture of the hip. B, Al-
disarticulation device. though socket adduction aligned the prosthesis with improved cosmesis, shortening of
hip abductors resulted in an energy-consuming lateral shift of the trunk over the pros-
thesis during stance phase.
(equinus) ankle and hindfoot varus
deformities due to the unopposed ac-
tion of the triceps surae. These may (Figure 18).An adductor magnus myo- cally, to accommodate hip flexion
desis, as part of a muscle-balanced contractures by prosthetic modifica-
be prevented after tarsometatarsal
(Lisfranc) and midtarsal (Chopart) transfemoral amputation as described tion in more distal transfemoral am-
amputations by preserving and/or re- by Gottschalk, 14 is the best preven- putations. More than 15° of hip flex-
attaching the anterior extrinsic tion. Active adduction exercises ion contracture will require a marked
muscle-tendon units of the forefoot should be performed as soon as they compensatory increase in lumbar lor-
to more proximal bone structures in a can be tolerated postoperatively. Ac- dosis that may lead to or aggravate
balanced fashion, combined with per- tive extension of the residual limb low back pain.
cutaneous lengthening of the Achilles while flexing the opposite limb to the
chest, in addition to lying prone for Prosthetic Considerations
tendon. 15 A postoperative cast applied
with the foot in neutral or mild dorsi- 15 minutes 3 times a day, will mini- When a prosthesis is prescribed for
flexion will prevent contracture until mize the chance of developing a hip patients with a significant flexion de-
a prosthesis is fashioned. An ankle- flex:ion contracture. Placing a pillow formity of the hip and/or knee, the
foot orthosis with an anterior ankle under the residual limb or excessive patient and the family should be in-
stop to stabilize the distal tibia can sitting should be avoid~ for the same formed about the relatively unattrac-
also be used. If a flexion contracture reason. Efforts should be directed to- tive appearance of the socket needed
develops despite these preventive ward early upright balance exercises to accommodate the physical defor-
measures, percutaneous Achilles ten- and walking with a walker or mity. If they do not understand the
don lengthening can be performed or crutches. rationale for the initial fitting and the
the amputation can be revised to a At the short transfemoral level, a fact that prosthesis use will tend to
Syme ankle disarticulation. flexion contracture of up to 25° may decrease the contracture, they may be
be accommodated by prosthetic very dissatisfied with the appearance
Transfemoral Level alignment. It is important to realize of the prosthesis and reject it. Chil-
At the transfemoral level, a flexion- that this flexed position limits hip ex- dren with knee and hip flexion con-
abduction contracture of the hip can tension power needed for prosthetic tractures are fitted using conventional
markedly increase the already bigh- knee stability. It is increasingly diffi- alignment techniques. Spontaneous
energy requirement for ambulation cult, both mechanically and cosmeti- use of the prosthesis will usually

Motor Control of the ing of a bursa becomes inflamed

swelling and tenderness may occur'.
Residual Limb Initial treatment includes rest, ice
Some patients have significant diffi- and nonsteroidal anti-inflammator;
culty coordinating muscle activity of drugs. If symptoms persist, the bUJsa
the residual limb after a lower limb can be aspirated under local anesilie-
amputation. Some of these problems sia and injected with 20 to 40 mg of
may be due to the physiologic effects long-acting corticosteroid medica-
of losing part of the limb. Provided tion. Excision of the bursa and the re-
there is no underlying neuromuscular dundant skin often associated with it
disease, a physical therapist can assist is sometimes required.
-.in retraining the quadriceps, ham-
strings, and hip musculature by using
several modalities such as muscle
Chronic Sinus
stimulation and biofeedback. Patients Formation
should not proceed to weight bearing In some patients, persistent serous or
in a prosthesis until adequate control synovial fluid drainage may come
of knee and hip extension is restored. from a bursa at the end of the tibia or
Figure 19 In this transtibial amputation, other long bone (Figure 19). A small
the sinus overlying the subcutaneous por-
tion of tibia (arrow) may communicate
Late Complications adhesive bandage on an outpatient's
residual limb showing minimal drain-
with t he bursa (*) at the distal end of the Late complications are those that oc- age may be the only indication of an
tibia. The bursa is adherent to the distal cur or become apparent after defini-
end of the tibia, and minimal bone resec- underlying problem such as a superfi-
tive prosthetic fitting. They include cial suture abscess, a bursal sinus
tion will remove the deep portion of the
bursa. A preoperative sinogram can clar- bursitis; chronic sinus drainage; epi- caused by a bone spur, or a low-grade
ify the location and extent of the bursa. dermoid cysts and inflamed sweat localized osteomyelitis. A good way to
lntraoperative injection of methylene glands; bone spurs; ulceration of ad- determine if a sinus is present is to
blue through a small catheter helps to herent, insensate, or bum-scarred
ensure its complete removal. probe the opening. A malleable metal
skin; phantom pain; bony overgrowth probe, a cotton-tipped applicator, or a
in children; fractures; degenerative ar- flexible polyethylene intravenous
stretch the contractures without spe- thritis; and back pain. Attention catheter may be safely introduced af-
cial treatment. should be directed initially to diagnos- fer adequate skin preparation. Sinus
ing the condition accurately. Because tracts are unlikely to heal with rest
Upper limb Amputations many of these problems are caused or and frequently become colonized or
Contractures also occur in upper aggravated by a poorly fitting prosthe- infected. They are best excised during
limb amputations.Limitation ofgleno- sis, optimizing the prosthetic fit and a noninflamed interval. Complete ex-
minimizing shear forces at the skin- cision of the sinus tract can be guided
h umeral abduction and forward flex-
socket interface are paramow1t. Local both by a preoperative sinogrnm and
ion is common in short transhumeral
modification of the socket or use of a an intraoperative injection of methyl-
amputations. If these contractures are
more compliant interface material ene blue (Figure 20). Plain radio-
severe, the patient may best be fitted
may decrease these forces sufficiently graphs of the residual limb may dem-
with a shoulder disarticulation-type to enable full activity.
prosthesis. Elbow flexion contracture onstrate underlying bone spurs or
occurs readily in a short transradial localized osteomyelitis. The latter can
amputation. Early range of motion Bursitis be confirmed by MRI or a positive
bone scan. These lesions must be ex-
with adequate analgesia is the best Amputees with bursitis have residual cised completely to effect a cure and
prevention and should commence 5 limb pain localized either within the allow the patient to proceed with re-
to 7 days postoperatively. Gentle mus- socket or at the edge of the socket. habilitation.
cle strengthening exercises can begin Careful clinical examination should
2 to 3 weeks postoperatively. If con- eliminate other possible causes, such
tractures become fixed, even an ex- as infection (infected hair follicle or Epidermoid
tensive program of stretching may be cellulitis), phlebitis, skin ulceration, Cysts/Inflamed
ineffective. Selective release of con- or abrasion. Bursae can form in areas
tracted muscles may be required to al- of chronic friction such as over the Sweat Glands
low fitting of a prosthesis. distal tibia, deep to the myofascial Epidermoid cysts and inflamed sweat
sleeve that covers the bone. If the lin- glands are seen most often in the

Occasionally, patients may experi-

ence pain in the residual limb during
walking. In patients with peripheral
vascular disease, this inay be due to
intermittent claudication. A careful
history should reveal that the onset of
the pain occurs quite regularly after
walking a specific distance. The pain
of claudication usually resolves after
standing or sitting for several min-
utes. This pattern may indicate bor-
derline ischemia in the muscles of the
posterior flap, but cessation of smok-
ing, even at this late stage, may relieve
the symptoms. The patient should be
urged to continue wallcing exercise in
an attempt to develop collateral circu-
lation. Evaluation by a vascular sur-
geon for the presence of treatable
proximal iliac and femoral artery ob-
structions is encouraged. The ampu-
tee should also be assured that modi-
fication of the prosthesis or
Figure 20 Management of a bursa in a transtibial residual limb A, Preoperative view fabrication of a new socket will not
showing the sinus in a central area overlying t he tibia. B, Ellipse of skin marked for ex-
cision of bursa. A local injection with methylene blue will stain the full extent of the help his or her symptoms.
bursa and sinus tract. C, Wound after excision of skin, subcutaneous tissue, and stained Whenever late pain occurs follow-
bursa. D, Wound closure. The wound healed promptly, and the patient was weight ing an amputation for tumor, local re-
bearing in 3 weeks. currence must be suspected. Clinical
assessment with appropriate imaging
(plain radiographs, bone scan, or
popliteal and inguinal areas second- creases swelling and promotes proper
MRI) should complete the workup.
ary to irritation from the prosthetic shaping to enhance early prosthetic The appropriate treatment will de-
socket. They may respond to adjust- fitting. A variety of conditions can pend on the type of tumor and its
ments of prosthetic fit combined with cause residual limb pain, including staging. Collaboration with an oncol-
warm soaks and antibiotics. Recur- severe preamputation pain from ogist experienced with management
rence and chronicity are common. trauma, adherent skin, bone spurs, a of the underlying tumor is essential.
The usual pattern is of increasingly prominent fibula, excessive localized
painful inflammation followed by pressure from the socket, nemomas,
spontaneous drainage. Once thick or claudication from vascular disease. Problematic Bony
cyst walls form, excision is usually Preamputation trauma involving Prominences
necessary. Daily cleaning of the resid- tissues adjacent to the level of ampu-
ual limb and socket liner with an an- Another late complication is created
tation can give rise to late pain. Dis- by bone spur formation or apposi-
tibacterial soap may be helpful in pre-
ruption of the tibiofibular inter- tional bone growth at the cut end of a
vention.
osseous membrane and the proximal long bone in a child (Figure 21) . Pain
tibiofibular joint ligaments can cause is due to localized pressure often as-
Residual Limb Pain painful instability of the fibula. Re- sociated with an inflamed bursa. Al-
view of the initial radiographs may though prosthetic modification may
All amputation wounds are painful in
the early postoperative phase. The show wide displacement of the fibula, relieve some local symptoms, local-
acute discomfort settles over 24 to indicative of interosseous membrane ized surgical excision of the bursa and
48 hours, and the discomfort further disruption. Pain relief may be ob- underlying bony spur may be re-
decreases gradually as the wound tained by stabilization of the fibula quired. Minimal periosteal stripping
heals. Some patients experience sig- either proximally, by fusion of the and copious lavage after bone cuts
nificant pain relief by compression of tibiofibular joint, or distally, by an during the initial surgery are believed
the residual limb in an elastic ban- Ertl procedure between the fibula and to miinimize the occurrence of spur
dage or a shrinker sock. This de- the tibia. 16 formation.

A prominent distal fibula or fibu-

lar head can cause pressure-related
pain within the socket. If the fibula is
left longer than the tibia, tenderness
associated with bursitis frequently oc-
curs over the distal prominence (Fig-
ure 22). Prosthetic modification may
be successful, but a surgical revision is
usually necessary. Care should be
taken to shorten the fibula 0.5 to
1.0 cm more than the tibia and cut a
posterolateral bevel at the time of the
initial amputation or revision. For
very short transtibial amputations
(within 5 cm of the tibial tubercle),
the proximal shaft and head of the
fibula should be excised. When excis-
ing the proximal fibula, the peroneal
nerve can be easily identified locally
and drawn distally with the knee
flexed, allowing excision of several
centimeters of the nerve. The result-
ant neuroma forms well proximal in
the thigh. If this is a secondary proce-
dure, the peroneal nerve should be
identified beside the biceps tendon
above the knee joint and a generous
section excised, thus avoiding an un-
Figure 21 A, AP radiograph shows bony spurs (arrows) of both the t ibia and fibula in a necessary and possibly problematic
24-year-old man who underwent an amputation at age 11 years. The patient had ex-
scar in the residual limb.
treme tenderness over the distal fibula. B, Lateral radiograph of the same residual limb.
Local excision of distal 2 cm of fibu la alone led to complete resolution of symptoms. •
c
Figure 22 A, Lateral radiograph of a transtibial amputation with an excessively long fibu la, causing localized pain on weight bearing.
B, The same residual limb with a hemostat in a sinus leading to a chronic bursa over the fibula. C, lntraoperative view shows excised
bursa and overly long fibu la (arrow), which was resected to 0.5 cm above the level of the tibia with a posterolateral bevel.

Figure 24 Bilateral transfemoral amputations in a nonambulatory patient. The muscle

groups were simply closed over the ends of the femurs rather than being sewn to bone.
Figure 23 Because of inadequate deep Note that the right femur protrudes from the skin and the left femur is in a subcutane-
soft-tissue coverage, this femur became• ous position.
prominent and painful 1 year after trans-
femora l amputation.
vent subcutaneous migration of the
femur (Figure 24).
Pain from prominent bone may
also occur in transfemoral amputa-
tions. This pain is not usually c~used Neurogenic Pain
by formation of a bone spur; rather, In transfemoral amputees using a
the femm may become prominent quadrilateral socket, burning dyses-
anterolaterally because of poor soft- thesia was once common in the early
tissue coverage associated with a hip weight-bearing phase. This was likely
flexion abduction contract ure (Figme due to excessive pressure on the pos-
23). This situation generally results
terior cutaneous nerve of the thigh.
from failure to perform a myodesis. Figure 25 Exploration of a painf ul left
The zone of irritation could include
Forces generated at the skin/socket transtibial residual limb. The amputee
the buttock, perineal region, and pos-
interface during weight bearing and had a positive Tinel's sign over each of
terior thigh. The increased use of is- the neuromas held in the hemostats-
walking can lead to pain and skin
chial containment sockets, which pro- saphenous medially (left), sural posteri-
breakdown. In the absence of break- orly (center), and superficial peroneal lat-
vide a better distribution of weight-
down, prosthetic modification may be erally (right).
bearing forces, has reduced the
effecrve for ambulatory patients, but
surgical revision with a myodesis may incidence of this complication.
still be required. Adductor magnus Neuroma formation is a natural is to modify the socket to minimize
and quadriceps myodesis with myo- response to nerve section because all pressure over the area. If this ap-
plastic reattachment of the hamstring cut nerves form neuromas to a greater proach is unsuccessful, local anes-
tendons and iliotibial band, as de- or lesser extent. If nerves are cut at a thetic and corticosteroid should be
scribed by Gottschalk, 14 may correct level that avoids both inclusion in the injected adjacent to the painful nod-
this problem in ambulatory patients wound scar and significant pressure ule. If symptoms persist, excision of
with distal transfemoral amputations. from the prosthesis, the resulting neu- the neUJroma by proximal division of
In nonambulatory patients, a simple romas should not cause symptoms. If the nerve as well as burying the nerve
overlapping myoplasty of the quadri- a tender nodule is found at the end of end within muscle may provide relief
ceps and hamstrings may be sufficient a cut nerve and local tapping causes (Figure 25). In areas such as the fibu-
to contain the femur; however, a sim- the tingling pain typical for that pa- lar neck or metacarpal heads, where
plified myodesis of the deep quadri- tient (Tinel's sign), it is likely to be a the neuroma is directly over a bony
ceps layer to bone will still help pre- symptomatic neuroma. The first step prominence, surgical treatment is rec-

Figure 26 A, Very short transtibial amputation in a 21-year-old trauma patient. A split-thickness skin graft was placed over the myo-
desed muscle to salvage 9.5 cm of tibial length. Note the central area of painfu l blistering over t he distal tibia that requi red the use of
a thigh corset and knee joints for 9 months. B, The same residual limb fol lowing circumferential advancement of redundant skin to
cover the anterodistal part of the tibia 9 months after t he skin graft. The end of t he t ibia is now covered with sound skin. The patient
was subsequently f itted with a supracondylar-suprapatellar prosthesis. C, Anterior view 10 years after injury. The grafted area is no
longer visible. D, Posterior view (patient prone). Note t hat t he grafted area has displaced posteriorly. The patient leads an active life,
including snow skiing and running while wearing a prosthesis.
ommended. With a peroneal neu- shear to a tolerable level. Partial un- prominences, especially in adults. The
roma, excision of a generous portion loading of forces by the addition of a skin graft may heal, but it remains
of the nerve well proximal to the fib- thigh corset and knee joints also may thin and insensate. When subjected to
ular head in the thigh, where it lies be beneficial. Some patients do not weight-bea1."i:ng loads, the tissue often
adjacent to the biceps tendon, usually respond to these conservative mea- breaks down, leading to a frustrating
relieves the symptoms. This approach sures and may require surgical revi- cycle of dressings and prolonged peri-
avoids a potentially painful scar over sion. ods of non-weight bearing followed
the fibular head and neck in the resid- After a transtibial amputation, scar by recurrent breakdown. Conse-
ual limb and allows a rapid return to can become adherent to bone follow- .iuently, the use of skin grafts over
prosthesis use. ing localized wound necrosis over the bony prominences in weight-bearing
distal tibia. A relatively aggressive ap- areas should be avoided whenever
proach to prompt removal of necrotic possible. When faced with this situa-
Adherent Skin tissue over the tibia is therefore justi- tion, it is worth trying a low-shear in-
Adherence of skin to bone can lead to fied. After scarring has occurred, the terface such as a silicone gel liner with
pain and/or ulceration when a pros- surgical approach is to excise an ellip- a thigh corset and knee joints to off-
thesis is used. Th.is condition occurs tically shaped adherent zone of skin load the grafted area. If redundant
because the adherent skin either does and advance a fascia! layer to cover skin is present or develops over time,
not possess enough compliance to the bone, allowing separate closure of a small area of graft can be excised
shear or direct forces or becomes is- skin with its subcutaneous tissue.5 If and local tissue advanced (Figure 26).
chemic because of tension in the skin, enough muscle atrophy has occurred, When larger areas are involved, con-
preventing blood flow. Appropriate the necessary tissue advancement may sultation with a plastic surgeon may
beveling of bones will reduce closure be achieved without resecting bone. If allow the use of a local sensate fascio-
tension by removing a bony promi- the closure will be under significant cutaneous graft. If no such flap is
nence. Careful soft-tissue closure, tension, some of the distal tibia available, the options are abandoning
providing a resilient myofascial layer should be resected. In this situation, prosthesis use or revising to a more
to cover the bone deep to the skin, distal bony prominence can be pre- proximal level.
can also help avoid this problem. If vented · by removing a proportionate Other sites where split-thickness
adherence occµrs early after surgery, length of fibula as well. Revision to a skin grafts are unlikely to stand up to
local skin mobilization by daily gen- transfemoral amputation level is prosthesis use are the adductor ten-
tle, persistent fingertip massage may rarely indicated. don region in the groin, the biceps
prevent breakdown. The use of a low- Adherence to bone and/or ulcer- tendon in the antecubital fossa, and
shear prosthetic interface, such as a ation is the reason that split-thickness the anterior axillary fold . Some areas
silicone gel liner, may reduce local skin grafts usually fail over bony of full-thickness skin defect may be

covered in two stages by the insertion must be taught to remove the pros- cent structures. This pressure is usu-
of a tissue expander W1der normal thesis and inspect their limbs on a ally generated by an increase in vol-
adjacent skin. The expanded skin can regular basis, especially during the wne from weight gain, peripheral
then be mobilized to cover the area of early phases of prosthesis use. If the edema, o r application 'of too many
skin graft to be excised. A plastic sur- patient's eyesight is poor, the limb socks. On attempted donning, the pa-
geon should be consulted and in- must be inspected by someone else. tient is unable to fully insert the limb
volved in this type of treatment. The with liner into the socket. The con-
challenge is determining when the tis- centrated pressure and shear forces
sue has expanded enough to cover
Poor Prosthetic Fit can result in local skin irritation or
the defect. A rotation flap of full- The volume of a residual limb de- ulceration. This also may be associ-
thickness skin and subcutaneous tis- creases most rapidly during the fust ated with a chro nic skin change over
sue from the abdomen is the best way year following amputation. Some vol- the dist al residual lin1b called verru-
to cover defects in the groin or ilie ume loss can be accommodated by cous hyperplasia, which is caused by
adductor tendon area. additional socks or socket padding. loss of skin cont act with the distal
The ideal surgical closure follow- Poor prosthetic fit can lead to abra- end of the socket. This edematous,
ing an amputation includes an ade- sions, bursitis, and thickening of the thickened skin can crack and become
quate soft-tissue envelope for the en- ~ kin in areas of increased or insuffi- painful, leading to local breakdown
closed bone or bones. Myodesis or cient pressure. These skin changes are and serous weeping with o r without
myoplasty ar e the two techniques often due to loss of suspension and infection. If the clinical cause of the
available to both provide distal pad- rotational control of the prosthesis or socket tightness is potentially revers-
ding and prevent adherence of the in- shear forces as the resid ual limb "pis- ible (eg, fluid retention in congestive
cisional scar to underlying bone. If tons" in the socket. The signs of in- heart failure or renal insufficiency),
the skin cannot slide over the under-• creased friction and/or pressure on temporary relief (1 to 2 weeks) can be
lying bone, it will not be able to toler- the skin from poor fit include persis- provided with a shrinker sock or a
ate the shear forces applied during tent erythema of the skin in weight- compression dressing. The same
use of a prosthesis. If wound closure bearing areas, erythema in areas of socket is reapplied, and a suppor t
is to involve split-thickness skin graft- skin not usually weight bearing, ten- stocking is provided for the remain-
ing, this should be applied only over derness under an erythematous area, ing limb. If the edema is not revers-
deeper soft tissues such as muscle. and callus or bursa formation. All ible, a new socket will be required;
The exceptions to this rule occur in members of the rehabilitation team however, the extra weight of the
upper limb amputations, which are must watch fo r signs of poor socket edematous limb may limit the pa-
not weight bearing, and in children, fit. tient's ability to walk. When weight
who generally do very well with split- Socket looseness can cause in- gain is the cause of socket tightness,
thickness skin grafts. creased friction and/or pressure over the most practical solution is fabrica-
the tibia and fibula, including the fib- tion of a new socket to accommodate
ular head and tibial tubercle as well as the increased volume of the residual
Insensate Skin the lower pole of the patella. The ad- limb.
Diminished sensation in the residual ditional pressures on these areas a re A third variant of poor fit is more
limb is common, especially in dia- caused by the residual limb sinking subtle and usually presents as an ill-
betic patients with sensory neuropa- too far into the socket because of a defined discomfort in the residual
thy. Sensory neuropathy is also seen decrease in volume of the residual limb. Examination reveals no evi-
in patients with myelomeningocele, limb from atrophy or weight loss, dence of pistoning with weight bear-
Hansen's disease (leprosy), alcoholic which makes the socket liner loose. ing, and the limb seats fully within
neuropathy, syphilis, congenital indif- The sinking is visually evident as the socket. Checking the fit with only
ference to pain, and spinal cord or pe- weight is transferred to the prosthesis the liner on may reveal excessive dis-
ripheral nerve trauma, among others. after heel contact. Although mild de- tal liner volume, especially in the sag-
These patients lack the normal pro- creases in volume can be accommo- ittal pla ne. Subtle signs of pressure
tective sensation to warn them of lo- dated with an increase in tl1e thick- over the distal subcutaneous portion
cal excess pressure or impending skin ness of socks and/or strategically of the tibia, such as erythema and
breakdown, so they continue to walk, placed partial socket padding; once abrasion, may be present after weight
either on the residual limb or the re- 10 to 15 plies of socks are needed, a bearing. In other words, the residual
maining foot, despite local pathology new socket and liner are usually re- limb has good proximal fit inside the
such as abrasions or ulcerations. quired for definitive management. brim but excessive motion distally.
These patients must understand that Socket tightness can cause tender- The distal tibia behaves like the clap-
serious soft-tissue infection can result ness at the socket brim due to direct per inside a bell, slapping back and
from a small ~n abrasion. They pressw-e on tl1e tibial tubercle or adja- fo rth against the liner each time the

overgrowth that can tent the skin and function in a prosthesis user. Trans-
even penetrate it (Figure 27). This tibial amputees with significant de-
phenomenon is seen in the humerus, generative arthritis of the hip may
fibula, tibia, and femur, and ceases also benefit from a total hip arthro-
when the growth plates close. This plasty.
can be maJlaged by the resection of Weight-bearing pain from degen-
sufficient bone to allow adequate soft- erative arthritis in the knee of a trans-
tissue coverage and closure, but over- tibial amputee may be partially re-
growth may recur several times before lieved by the addition of a thigh
skeletal maturity. Caps, plugs, bone corset and knee joint. This will allow
wax, chemical cautery, or electrocau- partial load transfer through the cor-
tery have not proved useful in con- set and joints to the thigh and thus
trolling overgrowth. The one excep- relieve some of the forces across the
tion appears to be the capping joint. Patellofemoral joint pain has
procedure developed by Pfeil and as- not proved to be a major concern ex-
sociates 17 to treat and prevent termi- cept in cases of recurrent lateral dislo-
nal osseous overgrowth in both con- cation of the patella, seen in amputees
genital transverse deficiencies and with excessive genu valgum. If slight
amputations. A cartilage-osseous varus realign ment of the prosthesis
graft, including a physis, is salvaged with padding of the lateral supra-
Figure 27 Appositional overgrowth of from a long bone or the posterior iliac coodylar extension is ineffective, sur-
the humerus that occurred after amputa- crest. After removal of the over- gical correction may be necessary.
tion in childhood. The amputee did not
growth, this graft is fixed firmly with This usually includes release of the
seek medical attention until th e humerus lateral capsule, separation of the vas-
had penetrated the skin. a screw or Kirschner wires to the dis-
tus lateralis from the intermuscular
tal diaphysis. Good incorporation of
septum, and advancement of the vas-
the grafts has been demonstrated,
knee is extended in swing phase. A tus medialis (Figure 28) . In cases of
with the added benefit of end-
internal derangement of the knee, ar-
weight-bearing radiograph of the re- weight-bearing in selected patients. 17
sidual limb-liner-socket interfaces throscopic eval uation and treatment
Proximal epiphysiodesis is contrain-
may reveal a distal void that allows can provide significant relief. If these
dicated because it will leave the child
this motion and also some distal measures prove inadequate, a total
with an unnecessarily short limb and
swelling as a result of proximal "chok- lcnee arthroplasty should be consid-
not affect the distal overgrowth.
ered.
ing" fro m the relatively tight socket
inlet. These problems may sometimes
Degenerative '-
be corrected by padding the socket Low Back Pain
void posteriorly. A new socket may be Arthritis A significant percentage of adults in
required if this modification does not Some patients will have preex1stmg the general population experiences
fully correct the problem. degenerative changes in joints proxi- low back pain. In ambulatory trans-
The recent emergence of com- mal to the amputation. Ambulation femoral and transtibial amputees, the
puter-based measurements of limb with a prosthesis may exacerbate ar- forces through the lower lumbar re-
and socket parameters has made the thritic symptoms because of altered gion are markedly increased because
identification of volume changes gait mechanics. Routine mediatl- ' the low back and pelvis help carry the
more objective. It is possible to scan management may provide significant weight of the prosthetic limb and
the initial shape of a patient's residual relief. Arthritis of the hip joint may be propel it forward with each step. Any
limb, calculate its volume, and store alleviated to some extent in a trans- preexisting low back pain would be
these data. Future measurements can femoral amputee because some body expected to increase with time and
then be compared with the original weight is transferred through the is- the aging process. In amputees with-
and used as the basis for the fabrica- chium to the socket. Hip joint com- out preexisting pain, back symptoms
tion of a new socket. pressive forces can be minimized by are likely to develop over time. In ad-
using light materials and by use of a dition, many transfemoral amputees
Bony Overgrowth in cane in the opposite hand to decrease develop a postoperative hip flexion
muscular effort across the affected contracture, further increasing him-
Children joint. If pain is not adequately re- bosacral stress. The best approach is
Amputations m children may be lieved, a total hip arthroplasty should prevention by maintaining general
complicated by appositional bony be considered to maintain walking physical fitness, including daily back

Ch apter 54: Musculoskeletal Complications 697
A 8
Figure 28 Left transtibial amputation in a 26-year-old woman who reported frequent

painful lateral dislocations of the patella despite a previous rea lignment procedure.
A, Under anesthesia, the patella was dislc!cated laterally with ease. B, Patella in reduced
position. Following release of the lateral capsule, separation of t he vastus lateral is from
t he intermuscular septum, and advancement of the vastus medialis, a new prosthesis
was aligned in slight varus with padding of the lateral supracondylar extension. Figure 29 Patient w ith right transtibial
amputation and comminuted, short ob-
lique right supracondylar fracture and
flexibility and strengthening exercises, jury is a fall while wearing the pros- left femoral shaft fracture. After 8 weeks
and avoiding weight gain. Acute epi- thesis. The injmies of greatest con- of bilateral skeletal traction, the patient
was treated with a bilateral cast-brace
sodes of low back pain may be man- cern here are those involving the technique for 5 months.
aged with analgesics, anti-inflam- residual 1-imb. The use of a knee joint
matory medication, stretching, and and thigh corset does not protect
strengthening. If significant leg pain against supracondylar fractures of the managed by non-weight bearing or
develops in a dermatomal distribu- femur in transtibial amputees, nor use of lightweight casts. The mass of
tion, appropriate investigation should does the use of a pelvic belt with a the residual limb is small and the
be conducted to rule out the possibil- metal hip joint protect transfemoral muscular forces across the fractures
ity of disk herniation. Care should be amputees from hip fractures. 18 are significantly diminished.
taken to maintain optimal prosthetic Restoration of the anatomic neck- For transtibial amputees, preserva-
fit and alignment so that limb-length shaft angle in displaced intertrochan- tion of knee motion and restoration
inequality or gait abnormalities do teric hip fractures is very important of limb alignment are crucial. 18 Pa-
not contribute to low back pain. to facilitate optimal function of the tients with stable supracondylar frac-
hip abductors. 15 Amputees are best tures should be treated surgically to
served by open reduction and internal allow early range of motion at the
Fractures fixation and early return to weight knee. Severely comminuted supra-
Appropriate management of fractures bearing. Displaced femoral neck frac- condylar fractures may be managed
in the residual limb following ampu- tures may be managed by multiple with immobilization for 4 to 6 weeks
tation can enable retmn to prosthesis screws, a sliding screw with sideplate, followed by cast bracing (Figure 29).
use. The general principles of fracture or endoprosthetic replacement (hemi- Adjustment of the prosthesis can
care apply equally to amputees: ob- arthroplasty or occasionally a total compensate for moderate malunion
tain and maintain fracture reduction. hip arthroplasty). Excision of the or loss of limb length. All efforts
Some modifications of treatment are femoral head alone will cause an un- should be made to minimize flexion
necessary because of the decreased stable gait, which could prevent a pre- contracture of the hip or knee joint.
distal limb mass and the associated viously ambulatory patient from For displaced intra-articular distal
diminution in forces causing dis- walking. Nondisplaced fractures in femoral or proximal tibial fractures,
placement of fracture fragments. 18 the intertrochanteric region and shaft open reduction and stable internal
The most common mechanism of in- in transfemoral amputees can be fixation followed by early range of

should be managed so as to maintain

TABLE 1 Regional Considerations for Lower Limb Amputations range of motion. This may be
Level of Amputation Problems Prevention/Treatment achieved with closed or open tech-
Metatarsophalangeal Migration of Leave 1 cm proximal phalanx or niques depending on the fr.acture pat-
first toe sesamoids suture f lexor hallucis brevis tern. Fractures of the forearm should
tendons to capsule be managed as with other patients.
Metatarsophalangeal Hallux valgus Prevention: second ray resection Fractures of both the radius and the
second toe initially
Treatment: resection with fusion ulna should be treated by open reduc-
base first toe tion and internal fixation. Fractures at
Transmetatarsal Painful Long plantar f lap the wrist should be treated to main-
metatarsals Bevel bone cuts plantarly tain both stability and range of mo-
Do not skin graft plantarly
tion.
Tarsometatarsal Plantar flex ion Release Achilles tendon at time
(Lisfranc) and varus of surgery
Splint/cast in dorsiflexion
Release Achilles tendon at time
Amputations
Midtarsal Plantar flexion
(Chopart) and varus of surgery Associated With
Transfer dorsiflexors to talus
Splint/cast in dorsiflexion Burns
Ankle disarticulation Migration of heel Postoperative casting
Maintain good prosthetic fit
Three major types of burns lead to
(Syme) pad
Consider soft-tissue revision amputations-electrical, chemical,
Transtibial Delayed wound Long posterior myofasciocutaneous and flash fire. Electrical injuries cause
healing flap tissue necrosis at both the entry and
Bevel anterior tibial cortex
exit areas. The electrical charge is
Symptomatic Identify and resect nerves proximal
to expected socket pressure areas,
transmitted preferentially along the
neuromas
including superficial peroneal, blood vessels and nerves, leading to
sural, tibial, and saphenous nerves tissue necrosis that gradually mani-
Bursitis Check prosthetic fit fests itself over 4 to 7 days. Despite
Inject with steroid if resistant to
conservative measures
this slow process of demarcation, in-
Excise if persistent or sinus develops dicated amputations and debride-
Transfemoral Flexion-abduction Myodesis for ambulatory patients ments should not be delayed; the pa-
contracture of Modified myodesis/myoplasty for tient's condition may deteriorate
hip nonambulatory patients
.apidly. Stimulation of muscle tissue
Transtibial or transfemoral Bone spurs Rinse wound well after bone cut
Trim edges of periosteum
with the electrocoagulator on a low
setting will help identify necrotic
Back pain Tends to increase with time
Prevent flexion contractures muscle for excision. All wounds
Back exercises often effective should be left open because secondary
debridement will be necessary in 1 to
3 days. Amputation wounds can be
motion will help minimize the occur- amputees should be managed as in slow to heal, aggravated by poor arte-
rence of knee flexion contractures. other patients: unstable fractures rial inflow, venous congestion, tissue
Careful assessment of the quality of should be reduced and stabilized by edema, and continuing or undetected
bone available for internal fixation is internal fixation. If the bones are os- muscle necrosis.
teopenic, closed treatment may yield A small percentage of patients with
necessary before commencing treat-
better results. Remember that the electrical burns of the upper limbs
ment. Special techniques using pin or
develop a11kylosis of the elbows from
wire fixation or bone cement may be blood supply is often compromised,
heterotopic ossification. The hetero-
required to augment screw fixation in and wound healing may be poor if
topic bone typically forms in a plane
osteoporotic bone. Threaded plates there is tension on the soft tissues.
deep to the triceps muscle and tendon
may also be beneficial in maintaining Fractures of a residual upper limb
along the distal humerus and may ex-
alignment. With these devices, the are rare. 18 Falls are less frequent than tend to the proximal ulna, creating a
screws thread . into the plate as they in lower limb amputees. In general, pain-free extracapsular ankylosis. The
are tightened, effectively locking the humeral fractures are treated by new bone may encase the ulnar nerve
bone into position. If bone quality is splinting. If delayed union or where it passes behind the elbow.
judged too poor to hold screws, malunion occurs, surgical stabiljza- Plain radiographs of the elbow usu-
closed management may be the best tion with bone grafting should be ally reveal the posterior bony bridge.
choice. Ankle fractures in partial foo t performed. Fractures about the elbow StJ.pplemental information may be

obtained by CT or MRI. The bone

mass is frequently matme within TABLE 2 Regional Considerations for Upper Limb Amputations
6 months of the burn injury and usu- Level of
ally does not recur after smgical re- Amput at ion Problems Preventionffreatment'
moval. Adjunctive measures such as Phalanx to Neuroma Careful attention to level of nerve
nonsteroidal anti-inflammatory med- metatarsal division
ication or radiation are not necessary. Wrist Reduced Avoid injury to distal radiou lnar joint
pronation-supination Early movement
A functiona l range of motion is re-
Transradial Joint contractures Early movement
stored in most cases. Limited pronation- Early movement
Chemical burns also present diffi- supination
Symptomatic neuromas Identify and resect nerves proximal to
culties with respect to wound healing
expected socket pressure areas
because, as in electrical burns, the Transhumeral Symptomatic neuromas As in transradial
area of injury is often more extensive Shoulder contracture Early movement
than initially appreciated. Aggressive Shoulder pain Early movement
Neck pain Gentle manipulation
lavage of adjacent tissues with an ap- Traction with management of
propriate diluent is essential. In con- degenerative disk disease if present
trast to electrical burns, with chemi-
cal burns the biologic level of
amputation should be clear following
over time there are recurrent episodes neuromata and bone spurs are best
initial debridement. Once this is es- with varying etiologies, the underly- treated by surgical excision . Fractures
tablished, wound heaLing should ing problem may be psychological in are managed as they are in the non-
progress normally. 1 origin. A pattern of unexplained amputee population. Unexplained re-
Flash fires can cause full-thickness problems, often requiring surgical current wound problems may be a
skin damage and permanently impair treatment, is characteristic in these presentation of psychiatric illness.
sensation and function of small individuals. Repeated surgical revi- Effective management of muscu-
joints, especially in the hand. These sions will not be successful. 19 These loskeleta] complications after ampu-
injuries are not prone to spread prox- individuals may benefit from psychi- tation requires early recognition of
imally as in electrical burns. Amputa- atric assessment and treatment. developing problems and prompt re-
tions performed proximal to the zone view. The nonsurgical members of the
of injury heal promptly. Flash fire rehabiHtation team-the cLiabetes
burns do not have the same propen- Summary nurse, home care aide, physiothera-
sity to form heterotopic bone as do Early complications after amputation pist, physiatrist, or prosthetist-are
electrical injuries. are due to inappropriate selection of often the first to encounter and report
amputation level, delayed wound heal- problems. Open communication of
Regional Considerations concerns among all members of the
ing, infection, trauma, and malnutri-
and Recurrent Unexplained tion. These can be minimized by com- full rehabilitation team will lead to
Problems prehensive preoperative assessment, early problem identification and
In addition to the general complica- careful surgical technique, and post- treatment.
tions described above, many regional operative splinting or casting. Minor
problems are specific to certain am- areas of wound necrosis can be treated References
putations. Table 1 describes problems with debridement and dressings. Full-
1. Jensen JS, Mandrup-Poulsen T, Kras-
and management techniques for thickness wound necrosis over the
nik M: Wound healing complications
lower limb amputations, and Table 2 tibia requires local excision and possi- following major amputations of the
focuses on upper limb amputations. bly local revision if a sin us exists. Ma- lower limb. Prosthet Orthot Int 1982;6:
On rare occasions, an amputee will jor wound healing problems may re- 105-107.
have recurrent skin problems that do quire revision to a more proximal 2. Lexier RR, Harrington IJ, Woods JM:
not fit the usual patterns of abrasion level. Joint flexion contractures and Lower extremity amputations: A
or ulceration. There may be a range of initial shaping of the residual limb to 5-year review and comparative study.
problems-excoriations, sores, ab- obtain optimal prosthetic rehabilita- Can I Surg 1987;30:374-376.
scesses, or deep infections. When tion also deserve close attention. 3. White RA, Nolan L, Harley D, et al:
these events occur in an immuno- Late complications after amputa- Noninvasive eval uation of peripheral
competent individual, self-injury tion include bursitis, skin problems, vascular disease using transcutaneous
could be a possible cause. Clearly, ap- neuromata, and fractures. These re- oxygen tension. Arn I Surg 1982;144:
propriate treatment should be pro- quire comprehensive assessment and 68-75.
vided for the medical condition. If usually nonsurgical treatment. Some

4. McCoUough NC III: Complications of view of the literatu.re. Arch Surg 2003; 14. Gottschalk F: Transfemoral amputa-
amputation su.rgery, in Epps CH (ed): 138:272-279. tion: Biomecha11ics and surgery. Clin
Complications in Orthopaedic Surgery, 9. Wunderlich RP, Peters EJ, Lavery LA: Orthop 1999;361:1 5-22.
ed 2. Philadelphia, PA, JB Lippincott Systemic hyperbaric oxygen therapy: 15. Wagne r FW Jr: Ampu tations of the
Company, 1986,vol 2, pp 1335-1367. Lower-extremity wound healing and foot and ankle, in Moore WS, Malone
5. Hadden W, Marks R, Murdoch G, the diabetic foot. Diabetes Care 2000; JM (eds): Lower Extremity Amputation.
Stewart C: Wedge resection of ampu- Philadelphia, PA, WB Saunders, 1989,
23: 1551-1555.
pp93-ll7.
tation stumps: A val uable salvage pro- 10. Ciaravino ME, FriedeU ML, Kammer-
cedure. J Bone Joint Surg Br 1987;69: locher TC: Is hyperbaric oxygen a use-
16. Ertl J: About amputation stumps.
306-308. Chirurg 1949;20:2 18-224.
ful adjunct in the management of
6. Wood MR, Hunter GA, Millstein SG: 17. Pfeil J, Marqua rdt E, Holtz T, Neithard
problem lower extremity wounds? Ann
FU, Schneider E, Carstens C: The
The value of stump split skin grafting Vase Surg 1996;10:558-562.
stump capping procedure to prevent
following amputation for trauma in 11. Dickhaut SC, DeLee JC, Page CP: Nu- or treat terminal osseous overgrowth.
adult upper and lower limb amputees. tritional status: Importance in predict- Prosthet Orthot Int I 991; 15:96-99.
Prosthet Orthot Int 1987;11 :71-74. ing wound-healing after amp utation. 18. Bowker )H, Rills BM, Ledbetter CA,
7. Kalani M, Jorneskog G, Naderi N, Lind J Bone Joint' Surg Am 1984;66:71-75. Hunter GA, Holliday P: Fractures in
F, Brismar K: Hyperbaric oxygen 12. Pinzur MS, Morrison C, Sage R, Stuck lower limbs with prior amp utation: A
(HBO) therapy in treatment of dia- R, Osterman H, Vrbos L: Syme's two- study of ninety cases. J Bone Joint Surg
betic foot ulcers: Long-term follow- stage amputation in insulin-requiring Am 1981;63:915-920.
up. J Diabetes Complications 2002;16: diabetics with gangrene of the fore- v
19. Hunter GA: Limb ampu tation and
153-158. foot. Foot Ankle 1991;11:394-396. re-amputation in association with
8. Wang C, Schwaitzberg S, Berliner E, 13. Dederich R: Technique of myoplastic chronic pain syndrome. Prosthet
Zarin DA, Lau J: Hyperbaric oxygen amputations. Ann R Coll Surg Engl Orthot Intl 985;9:92-94.
for treating wounds: A systematic re- 1967;40:222-226.

Skin Problems in the Amputee
S. William Levy, MD
Introduction
Skin lesions in the amputee must al- Numerous advances in the devel- the adductor region of the thigh, the
ways be taken seriously. A neglected opment of prostheses for transtibial groin, and the ischial tuberosity, all
lesion can lead to an e>..1:ensive skin and transfemoral amputees have oc- points of contact with the socket rim.
disorder that may be mentally, so-1 curred in the past few decades. At the If suction is used for suspension, the
cially, and economically disastrous to strong urging of amputees wishing to skin of the residual limb is subjected
the amputee. It is best to view any participate in sports with unusually to both positive and negative pres-
skin irritation, however minor, as po- high physical demands, lighter sure. The transtibia1 amputee usually
tentially dangerous and to treat it as weight, stronger prostheses with more has at least the upper third of the tibia
early as possible. This is esp'ecially dynamic action have been developed. remaining, and areas of pressure oc-
true in patients with diabetes. 1 A skin Many new designs are now reported cur over the anterior portion of the
problem should never be ignored in to store energy during stance phase tibia, as well as the sides and some-
the hope that it will heal of its own and release energy as the body weight times the end of the residual limb.
accord. Early attention to skin prob- progresses forward, thus helping to Mechanical rubbing over the prepa-
passively propel the limb. Numerous tellar and infrapatellar areas also oc-
lems avoids the frustrating situation
innovations in prosthesis suspension curs. With the older conventional
in which a person with a lower-limb
have been developed, and a variety of transtibial prostheses, constriction of
amputation must remain off the pros-
modifications are now available to fit soft tissues of the thigh by a thigh
thesis or use crutches because a ne-
individuals of differing physical char- corset can cause significant obstruc-
glected minor skin eruption or
acteristics and lifestyles. 2 tion to venous and lymphatic drain-
trauma has become severe.
The skin of an amputee who wears age of the residual limb. In addition,
Some amputees will be free of skin a prosthesis on a lower limb is sub- the skin of the residual limb may be-
problems for months or even years. In jected to numerous abuses. Most come irritated or experience an aller-
others, the skin is a weaker tissue, and prostheses have a snugly fitting socket gic reaction to the material used i11
frequent difficulties arise. The ortho- in which air cannot circulate freely, the manufacture of the prosthesis or
paedic surgeon, prosthetist, dermatol- thereby trapping perspiration. The to topi.cal agents applied by the pa-
ogist, and other medical personnel socket provides for weight bearing; tient or by a therapist.
who work with amputees should be uneven loading may ca use stress on Heal thy skin on the residual limb
aware of the conditions and danger localized areas of the skin of the re- is of utmost importance to the suc-
signals that are frequently forerunners sidual limb, such as intermittent cessful use of a prosthesis. If the nor-
of seriously incapacitating skin prob- stretching of the skin and friction mal skin condition cannot be main-
lems. Once an amputee has begun to from rubbing against the socket edge tained despite the daily wear and tear
use a lower limb prosthesis, the am- and interior surface. With some pros- the residual lin1b sustains, then the
putee will want to continue to ambu- theses, stump socks are worn to re- prosthesis cannot be worn, no matter
late on the limb, so the physician and duce the friction . Nylon sheaths, Te- how accurate the fit of the socket.
the prostl1etist should do their best to flon sheets, and gel liners have been This chapter describes the com-
prevent any disorder that might reused in recent years to reduce the mon skin problems and danger sig-
turn the amputee to crutches, bed shearing action. In tile transfemoral nals associated with the wearing of a
rest, or wheelchair. amputee, pressure may be exerted on lower limb prosthesis. Many of the is-

Edema
When a transfemoral amputee first
starts to wear a prosthesis with suc-
tion suspension, the skin must adapt
to an entirely new environment Sim-
ilarly, a transtibial amputee wearing a
total contact socket must adapt to the
heat, rubbing, and perspiration gener-
ated within the socket. Mild edema
and a reactive hyperemia, or redness,
should be expected at first. These
Figure 1 Distal stump edema and hemor- changes are the inevitable result of
rhage in the residual limb of a transtibial the altered conditions that are now
amput ee.
forced on the skin and subcutaneous
Figure 2 Erosion and ulceration of skin tissues of the residual limb. In most
on a residual limb from continued me- instances, they are relatively innocu-
sues addressed here are relevant to the chanical rubbing and injury.
care of the upper limb amputee as ous and do not require significant
well. In working with numerous am- therapy, and they can be minimized
putees over the years, I have assem- they should be asked to purchase a by gradual compression of the tissues
bled and correlated specific informa- plastic squeeze container of a liquid of the residual limb postoperatively
tion regarding various clinical detergent containing chlorhexidine with an elastic bandage or shrinker
problems. Because residual limb and gluconate, tridosan, or other antisep- sock. Compression can be begun be-
socket hygiene is important in rela- tic agent. These solutions are rela- fore the amputee begins wearing the
tion to several clinical disorders of the tively inexpensive and are available in prosthesis; after prosthesis use has be-
skin, a specific hygiene program for drugstores throughout the world, of- gun, it can be used at bedtime, when
care of the residual limb and socket is ten without a prescription. Alterna- the prosthesis is off. An incorrectly
described here. tively, a cake or bar soap may be used. fitted socket can contribute to edema
The amputee should be instructed in and redness by imposing a pressure
Skin Hygiene how to clean both the skin of the redistribution that can disturb local cir-
In the absence of a consensus as to sidual limb and the wall of the socket. culation.
what hygiene measures should be The cleaning routine should be fol- I
Continued use of a poorly fitting
used routinely, amputees have varied lowed nightly or every other night, prosthesis can cause edematous por-
and sometimes strange ideas about tions of the skin of the distal part of
depending on the rate of perspiration,
hygiene. If either the residual limb or the residual lin1b to become pinched
the degree of malodor, the bathing
the socket is not washed adequately, and strangulated within the socket,
habits of the person, and the climate.
maceration and malodor can result. which may cause ulceration or gan-
The residual limb should not be
Poor hygiene may be an important grene as a result of the impaired
washed in the morning unless a
factor in producing some pathologic blood supply. The pigmentary
stump sock is worn because the damp changes so often seen on the distal
conditions of the skin of the residual
skin may swell, stick to the socket, portion of the residual limbs of am-
limb, such as bacterial and fungal in-
and become irritated by friction dur- putees are due to deposits of hemo·
fections, eczema, intertrigo, and per-
sistent infected epidermoid cysts. I ing walking. For the same reason, the siderin, or blood pigment (Figure 1).
suggest a simple hygiene program us- best time to clean the inner wall of This temporary disorder is thought to
ing a bland soap or sudsing detergent, the socket is also at night. Some am- be vascular in origin, a venous and
which has often had a preventive or putees prefer to use witch hazel or lymphatic congestion producing
therapeutic effect on a skin disorder. rubbing alcohol compounds for edema and hemorrhage. Superficial
For example, tbis simple regimen has cleansing the wall of the socket. If a erosion of the skin in this area is un-
been curative for some persistent stump sock is worn, it should be common, in rare instances, deep ul-
eruptions of eczema on the residual changed daily and should be washed cers can result from continued me-
limb. Soaps or, detergents containing as soon as it is taken off, before per- chanical injury and poor skin
bacteriostatic or bactericidal agents spiration is allowed to dry in it. If the nutrition (Figure 2). In such cases, for
can belp to reduce the possibility of sock becomes wrinkled while drying, treatment to be successful, a derma-
subsequent infection. a plastic or rubber ball inserted into tologist must work with the ortho-
Amputees should be educated in the base of the sock during drying paedic surgeon and the prosthetist to
hygiene. As part of the instruction, will give it the correct shape. eliminate all mechanical factors con-

Chapter 55: Skin Problems in the Amputee 703
tributing to the edema, such as stran-

gulation by the socket or lack of total
contact distally.
Continued uneven mechanical
rubbing can produce thickened, li-
chenified areas on the skin or weep-
ing, superficial erosions (Figures 3
and 4). Occasional use of an oral di-
uretic in the morning and a shrinker
sock at night can be advantageous.
Excessive negative pressure in a socket Figure 3 Lichenified skin secondary to
can also contribute to circulatory mechanical rubbing on t he residual limb
of a 9-year-old boy with a transtibial am- Figure 4 Superficial erosi on secondary to
congestion and edema. Treatment mechanical rubbing on the residual limb
putation.
should be directed toward better sup- of a SO-year-old woman with a transf em-
port of the distal soft tissues by re- oral amputation.
storin g distal tissue contact, perhaps
by inserting a pad or raising the bot-
tom of the socket.
The interface of h uman tissue and
synthetic material is unavoidable in
the wearing of a prosthesis. Every am-
putee who wears a prosthesis experi-
ences skin adaptations and problem!
incidental to this intimate interface
because much of the involved skin is
not designed physiologically to with-
stand the environment and the vari-
ety of pressures that are inherent in
wearing a prosthesis. The disorders
described here are seen not only in
lower limb amputees but also in up-
per limb amputees. I have classified
common skin problems in lower limb Figure 6 Contact dermatitis secondary to
amputees and have described and the use of a silicone suspension sleeve.
Figure 5 Contact dermatitis secondary to
evaluated the treatment of numerous the use of a new plastic pad on the bot-
patients.3 Out of these studies, im- tom of the socket.
proved methods of treatment are con- burning when using a prosthetic
tinuing to evolve. In addition, newer socket, sock, or suspension sleeve.
contact with strong chemicals or
plastics, laminated carbons, titanium, Common sensitizers include nickel;
other known irritants. Allergic con-
and other metals developed through chromates ( used in leathers); wool
tact dermatitis can arise from the ap-
the United States National Aeronau- fats, especially lanolin, which is found
plication of topical agents by the pa-
tics and Space Administration pro- in many moisturizers and skin
tient or the physician or from agents
gram are presently being used in the creams; rubber additives; topical anti-
manufacture of many prostheses. De- used in the manufacture of the pros-
thetic socket. The socket wall itself biotics such as neomycin; and topical
spite these improvements in technol-
can also produce allergic contact der- anesthetics such as benzocaine or
ogy, computerization, and treatment,
matitis. Amputees may experience de- lidocaEne. Areas of itching eczema ap-
certain skin problems associated with
layed hypersensitivity to a variety of pearing at the site of contact with an
the wearing of a prosthesis continue
substances that come into contact irritant or allergen may be acute, with
to persist.
with the skin. Although older patients small blisters, swelling, or oozing of
Contact Dermatitis have been found to be less readily the skin, or more often chronic, with
Acute and chronic skin inflammatory sensitized to experimental allergens scaling and mild erythema.
reactions can result from contact with than are younger patients, in my own In many patients with contact der-
an irritant or allergen. 4 The irritant experience, allergic contact dermatitis matitis of the residual limb, the disor-
form of contact dermatitis, which is develops in many from a variety of der is caused by contact with chemi-
the most common, can result from agents, resulting in intense itching or cal substances that act either as a

distal portion of the residual limb.

The lesions can be dry and scaly at
times, whereas at other times they be-
come moist without apparent reason
(Figures 7 and 8). The condition often
fluctuates in severity, alternating from
a moist to dry state between active
and latent phases over a period of
weeks or months, and may cause the
patient much anxiety. In some pa-
Figure 7 Acute eczematization of t he dis- Figure 8 Chronic nonspecific eczematiza- tients the eczema appears to be sea-
tal residual limb. t ion of the distal residual limb. sonal, and in others it appears to be
related to periods of poor hygiene,
primary initant or drying agent or as cause of a given dermatitis. Because continuous standing, or unusually in-
a specific allergic sensitizer to the skin patch testing with strong concentra- tense physical activity.
(Figures 5 and 6). Knowledge of the tions of known primary irritants will A complete history, physical exam-
materials used in the manufacture of cause a reaction on almost any skin, ination, laboratory tests, and subse-
prostheses is necessary to understand sol utions of such substances are first quent observation of the clinical
and treat the problem adequately. diluted according to standard specifi- course of the condition is almost al-
Analysis of the heat, humidity, and cations to prevent a false-positive re- ways required to identify the cause of
friction within the socket is also im- recurrent eczema. One must ascertain
action and possible continued injury
the correct fit and alignment of a new
portant because these factors affect to the skin.5 I have investigated sev-
or old prosthesis to determine
the intensity of the reaction. For ex- eral cases of contact dermatitis in am-
whether the eczema may be related to
ample, varnishes, lacquers, plastics, putees and have found some to be
a fitting problem. In some patients,
and resins are frequently used in fin- due to neomycit1, epoxy resins, vari-
the onset of the eczema corresponds
ishing the inner lining of the prosthe- ous cements, Naugal1yde, waxes and
to the use of a new drug taken orally
sis socket. Incompletely cured plastic polishes, and even certain adhesive
or some unusual dietary changes.
resins and cements can produce a pri- tapes; in these cases, removing the
Other patients have been fou:nd to
mary irritant reaction or even cause suspected contactant resulted in a
have a significant history of recurrent
specific allergic sensitization. Foam cure, and patch testing after the acute
allergic eczema or have active eczema-
rubber cushions and plastic-covered process subsided confirmed the iden-
t<iUS lesions on other portions of the
pads used by some amputees on the tity of the offending agent. In in-
body. When eczema is secondary to
bottom of the socket can also produce stances of contact dermatitis in which the poor fit or alignment of the pros-
allergic sensitization over time. In ad- the irritant was not obvious and thesis or to edema and congestion of
dition, some cements and volatile patch test results were inconclusive, the terminal portion of the residual
substances used to repair prostheses temporary therapy directed at the limb, the fitting problems must be re-
(eg, plastics and epoxies) can produce symptoms was always successful. Cool solved before the condition will im-
either an irritant reaction or allergic or cold compresses, soothing anti-itch prove. Symptomatic topical therapy
sensitization. Any of these agents can lotions, and the appUcation of topical with immunomodulatory agents, hy-
produce contact dermatitis after corticosteroids or similar prepara- drocortisone, or other corticosteroid
weeks, months, or even years of con- tions have been beneficial in control- preparations ca n be temporarily ef-
titmed use. When contact dermatitis ling the process and allowing for im- fective, but the condition frequently
is suspected or diagnosed, every at- provement or cure. Of course, once recurs unless its cause can be identi-
tempt should be made to identify the an agent has been identified as the fied and eliminated.
substance that is responsible to avoid cause of a given reaction, it should be
future problems. In some patients, avoided as much as possible. All doc- Epidermoid Cysts
only a careful history will reveal that umented skin allergies should be Many authors have described an asso·
the use of a new cream, lotion, lubri- noted carefully on the patient's record ciation between wearing a prosthesis
cant, or cleansing agent coincided because systemic exposure to com- and the appearance of multiple cyst~,
with the onset. of the dermatitis. In pounds related chemical ly to the con- frequently called posttraumatic ep1-
other patients, over-the-counter topi- tact allergen may result in systemic al- dermoid cysts, in the skin of residual
cal antibiotics or "skin-toughening" lergic reactions. limbs.6 These cysts occur most fre-
agents can produce a dermatitis. Eczema of the residual limb is an quently in the areas covered by the
Patch tests are most informative in acute or chronic, persistent, weeping, upper medial margins of the prosthe·
pinpointing specific substances as the itching area of dermatitis over the sis in tra.nsfemoral amputees, but they

Chapter 55: Skin Pr oblems in the Amputee 705
Figure 10 A, Epidermoid cysts and sinuses over the adductor area of the thigh on a
29-year-old transf emoral amputee. B, Close-up of t he same patient.
Figure 9 Early epidermoid cysts over the
adductor portion of the thigh on a
16-year-old girl with a transfemoral am- I have found that epidermoid cysts
putation. arise when the surface keratin and the
epidermis become invaginated and
act as a foreign body. With continued
have also been seen in other areas and
friction and pressure from the pros-
in transtibial amputees. Usually the
thesis, the keratin plug and its under-
cysts do not appear until the patient
lying epidermis are displaced into the
has worn a prosthesis for months o~
corium, resulting in nonspecific in-
even years (Figures 9 through 11 ).
flammation and implanted epider-
In the transfemoral amputee, small
moid cysts. These cysts can remain
follicular keratin plugs characteristi-
quiet and asymptomatic for a long
cally develop in the skin of the in-
period or can, with secondary bacte-
guinal folds and/or the skin of the ad-
rial invasion by Staphylococcus or
ductor region of the thigh, along the
brim of the prosthesis. Similar plugs Streptococcus, become abscessed and Figure 11 Popliteal epidermoid cysts in
can occur over the inferior portion of produce the characteristic clinical pic- various stages on the res idual limb of a
ture. SO-year-old man with a transtibial ampu-
the buttock, where the posterior brim tation.
or ischial seat of the prosthesis rubs. Incision and drainage of an in-
Through the process outlined below, fected nodule or excision of a chronic,
some of these plugs may become isolated, noninfected nodule may give suction-suspension prosthesis to pre-
deeply implanted and develop into temporary relief, but no method of vent cyst formation. We have tried
nodules and cysts, with some lesions treatment is completely satisfactory. various gel socks and suspension
becoming as large as 5 cm in diame- With acute infection, hot compresses sleeves as socket liners to reduce fric-
ter. The lesions appear as round or and topical or oral antibiotics, se- tion over the pressme areas, especially
oval swellings deep within the skin. As lected through bacterial studies and over th.e brim of the socket. Polytet-
they gradually enlarge, they become sensitivity tests of the cystic fluid, are rafluoroethylene (Teflon) film, which
sensitive to touch or pressure, and the indicated. As the cyst localizes, inci- allows for a gliding action and pre-
skin may break down and erode or ul- sion and drainage may be temporar ily vents continued rubbing and pres-
cerate. If irritation by the prosthesis beneficial. Chronic epidermoid cysts sure, has been found satisfactory for
continues, the nodular swelling may can sometimes be minimized or even tl1is purpose. Teflon patches provide a
suddenly break and discharge a puru- eliminated by improving the fit and similar adhesive interface, designed to
lent or serosanguinous fluid . The si- alignment of the prosthesis. reduce friction over areas of maxi-
nus discharge may become chronic, At my institution, we use various mum rubbing and pressure, and can
making effective use of the prosthesis topical preparations such as 1% to be effective whether the surface envi-
impossible. These ruptured nodules 2.5% hydrocortisone lotions in an ef- ronment is wet or dry. When these
can be exceedingly tender and pain- fort to prevent or retard the inflam- newer liner materials are used, cysts
ful, and frequently scars remain after mation that follows formation of the are generally less common, and when
the cysts have eventually healed. If the keratin plug that may be the precur- they do occur, they are smaller and
break occurs within the deeper por- sor of the epidennoid cyst. We have less irritated. We have injected corti-
tion of the skin, subcutaneous inter- also developed a stump sock or ad- sone or its derivatives into the cysts
communicating sinuses may develop. ductor rim sock for use with the and their channels to reduce the in-

a
f
s
lnte
Inter!
trigo,
in Cl
there
of pe
OCCUI
e bacterial infection and Ono Figure 12
skin of the distal residual abscess on
Figure 13 Edema, cellulitis, and a pyo- folds
1r-old patient with a trans- limb of a 2
genic ulcer from bacterial infection on wher, tibial amp
m. the residual limb of a SO-year-old female each
diabetic patient with a transtibial ampu-
layer
tation.
:action. Topical application. flammato
costeroids to areas of from tion of
ction have been found limb. All subjects wore prostheses and fled c maximun
tmmation, but this pro- followed a satisfactory routine of skin skin to reduce
mporary, symptomatic hygiene. The skin of the residual limb depei vides on
Figure 14 Fungal filaments seen on direct bing. relief. N~
thod of treatment has was found to harbor more abundant
microscopic examination of scales re-
be completely satisfac- bacterial flora than did the skin of the chan been fom
moved from the skin of an amputee w ith
patient presents unique intact leg. In some patients, chronic a superficial fungal infection. and tory, and
.d prosthetic challenges. recurrent folliculitis can be cured by eczer therapeut
adherence to the routine hygiene pro- the o
time. Once-nightly application of the ing I
gram described earlier. In other pa- Bacte
I and Fungal tients, therapy may require a wet
newer antifungal agents can be cura- cant
r,s compress, incision and drainage of
tive. In patients for whom topical an- mafr lnfec1
tifungal agents are not effective, oral prost Bacteri
olliculitis boils after localization, oral or
antifungal antibiotics can be helpful
:ulitis is seen in ampu- parenteral use of antibiotics, and local 0th Bacterial
3Jld curative. Griseofulvin, ketocona-
y, oily skin. The condi- application of bacteriostatic or bacte- tees with
zole, fluconazole, itraconazole, or ter- Seve1
tted by sweating and by ricidal agents. Topical application of tion is a~
binafine taken orally for several weeks obse:
the socket wall. Bacte- oily or lanolin-containing prepara- can be curative in resistant cases. Su- rubbing 1
res id
is usually more severe tions should also be avoided, as their rial follic
perficial fungal infections of the skin gar is
~ng and summer, when use has been found to be associated of the residual limb may be difficult in the lat
have
·mth and perspiration with bacterial folliculitis. to eradicate completely, however, be- increased
as w
maceration within the cause of continued moisture, warmth, seen promote
1g bacterial invasion of Superficial Fungal socket, fa
and maceration within the socket. Al- mati
.e. In most patients the Infections though some patients have reported zem, the hair 1
ition is not serious, but Superficial fungal infections, such as anecdotaUy that socket liners must be res id resulting
pecially in diabetic pa- tinea corporis and tinea cruris, can discarded to prevent recurrence of a erup sometime
progress to furuncles, appear on any part of the residual fungal infection, there is no scientific well tients, it
n eczematous weeping, limb enclosed by the socket. A non- basis for this, any more than a pair of to d1 cellulitis,
-cial impetiginized pyo- specific, scaling, erythematous erup- shoes must be thrown away to prevent limb crusted, s1
s 12 and 13). Polliculitis tion can be diagnosed through cul- recurrence of athlete's foot. The fact is elsev denna (Fi
or boils, can also result ture and/or microscopic evidence of that a fungal infection is not com- the I and furuc
residual limb and/or the fw1gus filaments in scales or tiny pletely eradicated by treatment. treat from po
~. though the environ- blisters or vesicles removed from a Rather, the fungus is kept in a nonac- der, socket by
1~ socket can encourage given lesion (Figure 14). Chronic re- tive state by using an antifungal cal. ' ment witl
rth despite a conscien- current fungal infections are espe- cream at bedtime and perhaps an an- a ca: bacterial
:outine. Allende and as- cially common in amputees who per- tifungal powder after bathing daily to nati1 tious hygi
,ared the bacterial flora spire heavily. Therapy consists of keep the area dry. Active bacterial and estal sociates7 ,
the residual limb with fungistatic creams and powders ap- fungal infections are usually short· oft of the ski
the opposite, normal plied over an extended period of lived if the diagnosis is made early shot the flora
emy of Orthopaedic Surgeons American

and correct therapy is administered.

fortunately, most such infections re-
spond to topical medications.
lntertriginous Dermatitis
Jntertriginous dermatitis, or inter-
trigo, occurs in skin surfaces that are
in constant apposition and where
there is hypersecretion and retention
of perspiration. The condition usually
occurs in the inguinal or crural areas.
On occasion, however, it occurs in the Figure 15 Psoriasis on t he distal residua l limb (A) and elbow (B).
folds at the end of a residual limb,
where two surfaces of skin rub against
each other and where the protective
layer of keratin is removed by fric-
tion. Continued friction and pressure
from the socket may result in licbeni-
fied or pigmented skin. The thickened
skin may subsequently itch or burn,
depending on the severity of the rub-
bing. A chronic disorder may develop,
characterized by deep, painful fissure~
and secondary infection along with
eczematization. Careful cleansing of
the opposing folds and the use of dry-
ing powders or mild drying lotions
can be beneficial. Frequently, this der-
matitis can be relieved by proper
Figure 16 Blisters from rubbing of the prosthesis in patients with diabetes. A, Pretibial
prosthetic fit and alignment. blister. B, Blister on the distal residua l limb.
Ot her Skin Disorders

Several chronic dermatoses have been licular nodules, and comedones. Pso- chronic and disabling. Candidal, or
observed to localize on the skin of the riasis usually presents as pink to red yeast, infections are not uncommon
residual limb. Patients with acne vul- plaques on the skin of the residual in the groin a11d on the residual limb
garis of the face and back sometimes limb with similar lesions on the el- following a course of antibiotics for
have acne lesions on the residual limb bows, knees, and trunk (Figure 15). some other disorder. Diabetic der-
as well. Similar localization has been Even a small skin biopsy can corrobo- mopathy, which presents as bullae, or
seen in patients with seborrheic der- rate the correct diagnosis. blisters, from the rubbing of the pros-
matitis, folliculitis, and atopic ec- thesis against the skin, requires sev-
zema. Localization on the skin of the Skin Disorders in eral weeks for complete healing (Fig-
resid ual limb following a general Individuals With Diabetes ure 16 ).
eruption is not unusual. Psoriasis, as
The skin of individuals with diabetes
well as lichen planus, has been known
is especially prone to chronic disor-
Growths
to develop on the skin of the residual
ders that can be serious and disabling. Viral verrucae, or warts, on the skin
limb, with a few lesions being present
Bacterial and fungal infections are of the residual limb are common and
elsewhere on the body. 3 To improve
common in amputees with uncon- aTe treated by cauterization. Simple
the local eruption, it is important to
trolled diabetes. A high blood glucose cutaneous papillomas (Figure 17) are
treat the generalized cutaneous disor-
der, so an accurate diagnosis is criti- level can lead to folliculitis on the re- easily removed. Cutaneous horns and
cal. To establish an accurate diagnosis, sidual limb or elsewhere on the body. warty keratoses are also common. All
a careful history and physical exami- Ulcerations and erosions of the skin of these can be treated by using a lo-
nation are of utmost importance. To must be diagnosed and treated early cal anesthetic and superficially re-
establish a diagnosis of acne, the skin to prevent serious infection or osteo- moving the lesion. This seldom re-
of the face, neck, back, and chest rnyelitis. Painful deep ulcers and quires a large surgical excision.
should be examined for pustules, fol- edematous processes . can become Healing is usually by secondary inten-

Figure 18 A, Chronic ulcer of 2 years' duration on the distal residual limb on a 42-year-
Figure 17 Cutaneous papilloma on the old man with a transtibial amputation, secondary to edema and a poorly fitting pros-
residual limb. To avoid irritat ion, cutane- thesis. B, Healed ulcer 6 weeks after reduction of edema and correction of the pros-
ous papillomas can be excised and the thetic socket f it.
base cauterized.
disorder. Somtimes localized pressure

from a poorly fitting prosthesis pro-
duces erosion, followed by ulceration
(Figure 18).
Persistent edema must be cor-
rected early to avoid ulceration. Ma-
lignant ulcers can develop within
chronic ulcerations; therefore, every
effort should be made to treat the
process before it becomes chronic.
Also, with repeated infection and ul-
Figure 19 Short transtibial residual limb ceration of the skin, the amputation
with an adherent scar and traumatic ul- scar may adhere to the underlying
cerations. \ubcutaneous tissues, inviting further
erosion and ulceration (Figure 19).
tion and occurs within a short period Surgery to free the scar in the bow1d
of time. Skin cauterization following area may then be necessary to allow
effective prosthesis use. The cause of
removal of a lesion usually heals
the stump ulceration must always be
within 2 to 3 weeks. Figure 20 Squamous cell carcinoma sec-
ondary to verrucous hyperplasia with ul- identified and corrective therapy dis-
Tumors of the skin of the residual
ceration on the residual limb of a trans- cussed with the orthopaedic surgeon
limb can be benign or malignant. I
tibial amputee. The patient died from and prosthetist.
have removed small basal and squa- metastases to bone and lung.
mous cell carcinomas without inci- Verrucous Hyperplasia
dent, and healing has been successful A verrucous, or warty, condition of the
and without recurrence. When exci- required amputation because of lym-
skin of the distal portion of the resid·
sion of skin of the distal residual limb phangioma; the condition recurred,
ual limb is common (Figure 20). Some
is indicated for squamous cell carci- with subsequent lymphangiosarcoma
describe the disorder as an invasion of
noma associated with verrucous hy- developing and death. In such cases,
the common wart virus into the skin,
perplasia, a well-planned plastic pro- an early, accurate diagnosis is of ut-
while others believe that the condition
cedure that will ensure complete most importance. is always associated with malignan·
removal of the malignancy and pre- cy.8 •9 I have treated many cases of ve.r-
vent recurrenc~ of the hyperplasia is Chronic Ulcers
rucous hyperplasia in amputees; 1n
crucial. The goal is to maintain a well- Chronic ulcers of the residual limb most patients, the process has been en·
formed and well-padded distal resid- may result from bacterial infection, tirely reversible3 • 10 (Figure 21). .
ual limb that will tolerate significant from radiation therapy, or from poor Verrucous hyperplasia of the sklll
compression within the distal socket. cutaneous nutrition secondary to of the residual limb can be associated
However, I have had two patients who edema or to an underlying vascular with ulceration, in addition to edema

Figure 21 Squamous cell carcinoma in a SS-year-old man with a Syme ankle disarticulation who presented with verrucous hyperplasia
of many months' duration. Excision of the skin of the distal residual limb proved successful, and the patient had no recurrence on
s-year follow-up. A, Early ulceration with verrucous hyperplasia. B, Appearance of the limb several months later, when the patient pre-
sented with infection, fever, ulceration, and malodor. C, Appearance of the limb 3 months later following excision of skin of t he distal
residual limb and correction of the fit of the distal prosthesis socket. There has been no evidence of recurrence of the carcinoma.
Figure 22 Reversible verrucous hyperp lasia of 2 years' duration on the residual limb of a Figure 23 Severe verrucous hyperplasia
54-year-old transtibial amputee. A, Before compression, the limb has a warty appear- . on the residual limb of a 34-year-old man
ance. B, After partial end-bearing compression and correction of the fit of the prosthesis with a transfemoral amputation second-
socket, the skin is completely clear. ary to proximal strangulation from a
poorly f itting prosthetic socket.
(Figures 22 and 23). Many patients slowly resolved. The greater the com-
endure this condition for months or pression, the more immediate and fection. Although these factors may
even years, seeking help from various lasting was the improvement. As a re- be present in combination, it is clear
health professionals and being treated sult of our investigation, the engi- from our studies that a poor pressure
with topical preparations and other neers and prosthetists modified the gradient, which tends to drive fluids
forms of therapy without effect, or, at prosthetic design to provide compres- into the distal tissues, plays an espe-
best, realizing only temporary benefit. sion of the tissues at the end of the re- cially important role. This occurs
My colleague and I found that exter- sidual limb. After several weeks, the whenever the proximal tissues experi-
nal compression, in combination with verrucous condition gradually disap- ence greater pressure than do the dis-
adequate control of bacterial infec- peared and did not recur, as long as tal tissues. Edema is likely to develop
tion and edema, is the best method of the compression was continued. The in the redundant, unsupported tissues
treatment. 10 In the transtibial ampu- successful treatment of this disorder of the residual limb before prosthetic
tees with verrucous hyperplasia we is an example of the need for cooper- treatmen.t because of the lack of sup-
treated, the distal part of the residual ation among various professionals to port for and pressure on the terminal
limb was edematous, and it dangled provide the maximum benefit to the tissues and the absence of any pump-
without sufficient distal support in individual amputee. ing action by the muscles. 11 A
the socket. Once the end of the limb Verrucous hyperplasia appears to shrinker sock used continually until
was compressed by means of a tem- be secondary to a vascular disorder prosthetic fitting and thereafter,
porary platform in the socket built up related to poor prosthetic fit and whenever a prosthesis is not worn, is
with cushions, the warty condition alignment and, possibly, bacterial in- distinctly advantageous. If the ampu-

tee is then fitted with a prosthesis that Calvo K: Analysis of below-knee sus- 9. Schwartz RA, Bagley MP, Janniger CK,
distributes pressure properly, the pension systems: Effect on gait. Lambert WC: Verrucous carcinoma of
edema will subside. However, if the J Rehabil Res Dev 1990;27:385-396. a leg amputation stump.
prosthesis produces greater proximaJ 3. Levy SW (ed): Skin Problems of the Dermatologica 1991;182:193-195.
than distaJ pressures, the edema will Amputee. St Louis, MO, WH Green, 10. Levy SW, Barnes GH: Verrucous hy-
increase and verrucous hyperplasia 1983. perplasia of amputation stump. Arch
Dermatol 1956;74:448-449.
can resuJt. 4. Lyon CC, Kulkarni J, Zimerson E, Van
Ross E, Beck MH: Skin disorders in 11. Golbranson FL, Asbelle C, Strand D:
amputees. J Am Acad Dermatol 2000; Immediate postsurgical fitting and
Summary 42:501 -507. early ambulation: A new concept in
amputee rehabilitation. Clin Orthop
Through the combined efforts of or- 5. Fisher AA (ed) : Contact Dermatitis, 1968;56: 119-13 l.
thopaedic surgeons, prosthetists, ened 3. Philadelphia, PA, Lea & Febiger,
12. Persson B: Lower limb amputation:
gineers, and dermatologists, the many l986.
Part l. Amputation methods: A 10
skin problems of the amputee can be 6. Allende MF, Levy SW, Barnes GH: Epi- year literature review. Prosthet Orthot
treated effectively. The importance of dermoid cysts in amputees. Acta Denn Int 2001;25:7- 13.
early recognition and treatment of the Venereol 1963;43:56-67. 13. Geertzen JH, Mar tina JD, Rietman HS:
common skin disorders of residual 7. Allende MF, Barnes GH, Levy SW, Lower limb amputation: Part 2. Reha-
limbs cannot be overemphasized. 12• 14 O'Reilly WJ: The bacterial flora of the biliation: A IO year Literature review.
skin of amputation stumps. J Invest Prosthet Orthot Int 2001;25:14-20.
Dermatol 1961;36:165-166. 14. Cochrane H, Orsi K, Reilly P: Lower
References 8. Gillis L (ed) : Amputations. London, limb amputa tio n: Part 3. Prosthetics:
1. Jelinek JE: (ed): The Skin In Diabetes. England, W Heinemann Medical A 10 year literature review. Prosthet
Philadelphia, PA, Lea & Febiger, 1986. Books, 1954. Orthot Int 2001;25:21-28.
2. Wirta RW, Golbranson FL, Mason R,

Chronic Pain Management
Dawn M. Ehde, PhD
Introduction
Pain after limb amputation is unfor- "an unpleasant sensory and emo- procedures, or disease. 3 By definition,
tunately an all too common conse- tional experience associated with ac- acute pain lasts for a limited time and
quence. Amputation-related pain can tual or potential tissue damage or de- remits as the underlying injury or dis-
become chronk and, for some indi- scribed in terms of such damage." ' ease heals. Thus, it differs from
1
viduals, limit quality of life and func- The IASP defines chronic pain as re- chronic pain in both duration and
tional capacity. Living with chronic current or persistent pain that is etiology. As will be discussed later, the
pain can change one's outlook, one's present for more than 6 months. This two pain types also differ in their op-
personality, and one's relationships. includes pain that persists beyond ex- timal treatment.
As the French philosopher Marcel pected healing time. There are at least
Proust said, "To kindness and to three subtypes of chronic pain. One is Multidimensional Construct
knowledge we make promises onJy. the result of an identified, ongoing of Pain
Pain we obey." disease process, such as chronic pan- In the clinic, pain is often thought of
In the past quarter century, re- creatitis or cancer, that results in pain.
as a one-dimensional construct, with
search, particularly that on phantom Another subtype is that with clear ev-
patients typically asked to rate pain
limb pain, has advanced our under- idence of injury to the peripheral or
on a numeric rating scale ranging
standing of chronic pain in individu- central nervous system; phantom
from absence of pain to severe pain.
als with limb Joss. In this chapter we limb pain is one example of this sub-
In contrast, pain researchers and clin-
summarize what is currently known type. The third is chronic pain whose
ical specialists view pain as a multidi-
concerning the nature, scope, and pathophysiology is either undetect-
treatment of chronic pain with ac- mensional construct with several rele-
able by current diagnostic procedures
quired limb loss. We discuss the prev- or is of a degree that does not fully vant dimensions, including, but not
alence, severity, and impact of pain as explain the symptoms or apparent limited to, location, frequency, dura-
well as the factors that contribute to, disability. Examples of this third sub- tion, intensity, effect, and pain-related
or are associated with, adaptation to type include chronic back pain and fi - disabilitry. 4
chronic pain in this population. Phar- bromyalgia. This subtype is the most Pain location specifies the site
macologic and rehabilitation ap- perplexing to health care profession- where pain is experienced. In individ-
proaches to pain management are also als and to persons experiencing this uals with acquired amputation, the
discussed. Answers to the research and type of pain. As will be discussed, it is phantom limb and the residual limb
clinical questions that grow out of this likely that some amputees may have are the areas typically assessed. The
knowledge will contribute to our long- pain that fits into this third category. frequency and duration of pain are
term goal of reducing pain and suffer- Although not the focus of this also commonly assessed and involve
in g in persons with limb loss. chapter, acute pain warrants defini- when and how long pain is experi-
tion because severe acute pain is a risk enced. To a lesser extent, pain inten-
factor for the development of chronic sity, which involves the severity of the
Conceptua I Issues paio. 2 Acute pain may be defined as pain, is also assessed in studies of
Definitions that elicited by activating nociceptive postamp utation pain and is also com-
The International Association for the transducers at the site of local tissue monly evaluated clinically. Pain inten-
Study of Pain (IASP) defines pain as damage because of trauma, surgical sity is typically assessed using a nu-

meric rating scale. The literature nervous system mechanisms and pro- tance of distinguishing among
varies widely as to the type of pain in- vides a physiologic basis for psycho- nociception, pain, suffering, and pain
tensity studied (eg, worst, average, logical factors in pain perception. Af- behavior. Nociception is defined as
least, usual). 5 The affective compo- ter its introduction into the field, this the activation of A-delta and C-fiber
nent of pain has received the least at- model radically changed the way that axons by mechanical, t hermal, or
tention in the amputation literature. researchers and clinicians thought chemical energies that are capable of
Pain affect is defined as the emotional about pain. It spurred physiologic re- damaging body tissues. Nociception
arousal and disruption produced by search on pain, including research- typically leads to pain, which is de-
pain (the "bothersomeness") . It is im- identified psychological variables, and fined as the perception of a noxious
portant to note that pain affect is dis- demonstrated how they modulate stimulus. Pain involves conscious
tinct from pain intensity; for exam- pain perception. The model also em- awareness, appraisal, ascription of
ple, one may have intense pain but phasized that pain is not exclusively meaning, and learning and, thus, is
not be upset or bothered by it. Finally, sensory, and, hence, simply measuring seen as a perceptual process compris-
pain-related disability refers to the pain intensity is inadequate. Most sig- ing the integration and modulation of
degree that chronic pain interferes nificantly, the gate-control theory em- a number of afferent and efferent
with activities and quality of life. Few phasizes that there is not a one-to-one processes. Pain often leads to suffer-
studies have examined the disability relationship between injury or disease ing, defined as a negative affective or
attributable to chronic pain in pa- severity and pain symptoms. emotional response generated in the
tients with limb loss. The biopsychosocial model, often brain in response to pain and other
considered an extension of the gate- stressors associated with tl1e pain ex-
Conceptual Models of Pain control theory, conceptualizes chronic perience, such as anxiety, fear, dis-
In addition to understanding the pain as the res ult of the complex in- tress, occupational problems, inter-
multiple dimensions of the pain expe- personal disruption, and economic
teraction of biologic, psychological,
rience, it is also important to under- distress. Suffering is a personal expe-
and social variables. With in this
stand the conceptual models of rience that can only be observed indi-
model, these factors interact in a dy-
chronic pain that have influenced rectly if the person engages in a be-
namic process, affecting a person's ex-
thinking and research over time. havior that is attributable to the
perience of pain. This model ac-
These models include the biomedical suffering. Specifically, suffering may
knowledges that biologic factors are
model, the gate-control theory of lead to pain behavior, which is de-
central to the experience of pain for
pain, and the biopsychosocial model. fined as "the things people do when
most, if not all, persons with pain.9 lt
The biomedical model assumes they suffer or are in pain." 17 Pain be-
also argues that psychosocial factors,
that pain results from a specific dis- 11aviors are verbal or nonverbal be-
such as the responses of family and haviors that serve to communicate
ease process and that it is synonymous
significant others to pain behaviors 10 that pain is being experienced. Exam-
with tissue injury and nociceptive
and pain-related cognitions, beliefs, ples of pain behaviors include moan-
stimulation. In this model, diagnosis
and coping behaviors 11 influence ading, grimacing, limping, lying down,
is confirmed by objective tests, with
justment to chronic pain, including rubbing the affected area, feeling un-
treatment directed toward correcting
psychological distress, pain-related able to work, seeking health care, and
the organic dysfunction. Psychosocial
disability, and health care utiliza- taking pain medications. All pain be-
factors are viewed as reactions to pain
tion.12'13 This model accounts for the haviors are observable and quantifi-
rather than as contributors. This dual-
diversity in the expression of and re- able. Nociception, pain, and suffering
istic model assumes that symptoms
sponses to pain. It has also signifi- are individual, private, internal
are either psychogenic or organic, de-
spite no empirical evidence for this di- cantly advanced our understanding of events, the existence of which in an-
16
chotomy. This model has long been some of the variability in individuals' other person can only be inferred.
criticized for failing to recognize psy- adjustment to chronic pain 11 •14 and An important caveat to this con-
chosocial variables in chronic pain or has provided a useful theoretical cept is that an individual does not
the interaction of these variables with framework for treatment. 15 Finally, necessarily experience all four aspects
path ophysiology.3·6 this model incorporates rehabilitation of this model (nociception, pain, suf-
The gate-control theory of pain7 •8 approaches with medically based fering, and pain behavior) simulta·
conceptualizes pain as a multidimen- treatments. neously and, in fact, may experience
sional phenomenon with motivational- one or more without the others. for
affective, cognitive-evaluative, and
Additional Concepts That example, an athlete may fracture a
sensory-physiologic components, all Distinguish Pain bone in his h and during a crucial play
of which can potentiate or moderate In addition to these conceptual mod- of a football game and thus have no·
pain perception. This model includes els, several prominent pain research- ciception without experiencing a~Y
psychological factors as well as central ers4·10·16 have argued for the impor- pain or suffering or exhibiting pain

Chapter 56: Chronic Pain Management 713
l Figure 2 A more modern sculpture of

th e homunculus from the Glasgow Sci-
ence Centre (Glasgow, Scotland) repre-
senting a human being modified in pro-
portions that correspond to the brain's
cortical map. (Courtesy of Glasgow Sci-
ence Center, Glasgow, Scotland.)
chological or personality disorder.

More recently, phantom limb pain has
been viewed as a natural and com-
mon response to limb loss with a
!- J
physiologic, rather than psychologi-
cal, basis. 1 8• 19 Interestingly, dming the
last few decades, as theories of phan-
tom limb pain have evolved from a
primarily psychological to a physio-
Figure 1 The historic illustration from Penfield and Rasmussen of the amount of cortex
logic focus, models of other chronic
dedicated to different anatomic areas. (Reproduced with permission from Penfield W,
Rasmussen T: Homunculus moteur in The Cerebral Cortex of M an: A Clinical Study of Lo- pain problems have broadened from
calisation of Function. New York, NY, Hafner Publishing Co, 1957.) an almost exclusively biomedical ap-
proach to incorporate psychosocial
variables. 20•21 Thus, for the purposes
behavior until he leaves the game and proportional to the size of the part. of this chapter, we will examine
realizes that he is injured. Similarly, For example, the thigh has very small chronic pain secondary to limb loss
an individual may walk on hot coals representation, whereas that of the from a biopsychosocial model that
without feeling pain or suffering. [n hand is very large. The homunculus is views chronic pain and suffering as a
contrast, an amputee may perceive a way to illustrate the body according complex phenomenon with multiple
phantom limb pain without nocicep- to the amount of cerebral cortex de- dimensions and factors.
tion. AJternatively, a stoic person may voted to each area. This may, in part,
experience nociception, pain, and suf- explain why individuals report more
fering without exhibiting any pain be- intense and vivid phantom sensation Types of Phantom
haviors. and phantom pain in the hand and and Residual Limb
Individuals with limb loss often refoot compared with the knee or elbow
port that phantom pain is most in- (Figures l and 2).
Pain and Sensation
tense in the hand or foot. Over time, To summarize, the literature views Nonpainful Phantom Limb
as the phantom feeling lessens, they chronic pain as a multidimensional Sensations
often describe a telescoping or short- experience that involves not only sen- In addition to phantom limb pain,
ening of the limb, with the phantom sory and physiologic processes but nonpainful phantom limb sensations
hand or foot moving closer to the also psychosocial, behavioral, and en- are typical. 22 For example, an ampu-
amputation site. The cortex of the vironmental factors. This is in con- tee may have a feeling that a missing
brain has areas dedicated to all parts trast to the traditional phantom limb foot is wrapped in cotton or that a
of the body. The amount of brain cor- pain literature, which presented phan- missing limb is actually present.
tex that represents each part is not tom limb pain as a symptom of a psy- These sensations can take a variety of

forms, such as touch, pressure, tem- by Smitl1 and associates, 28 part1C1- time to time. 26 ' 31-34 Recent studies
perature, itch, posture, or location in pants in this community-dwelling conducted in large nonclinical sam-
space.22• 23 They can also involve feel- sample had lived with their amputa- ples have confirmed its high preva- SJ
ings of movement in the phantom tions a long time, an average of 14.2 lence.28 •29•35 For exan1ple, in a ran- tJ
limb. For some, an occurrence re- years (range =6 months to 74 years), dom sample of 526 British veterans sl
ferred to as "telescoping" can happen and described their sensations as in- with amputations, 55% had phantom p
when the amputee senses that the dis- termittent (71 %) . Thus, nonpainful limb pain. 36 Other recent studies have p
tal part of the phantom limb is mov- sensations cannot be assumed to re- reported even higher rates. In one tl
ing progressively closer to the residual mit after surgery; rather, they appear large study of 255 community- p
limb over time. to be chronic for many individuals dwelling adults with lower limb am- tJ
The methodology of much of the with limb loss. putations (mean years since amputa- 11
research on nonpainful phantom sen- Less is known about the prevalence tion = 14), 72% of these respondents h
sations has varied so greatly that the of phantom limb sensations in upper had phantom limb pain (most com- ti
prevalence of the experience remains limb amputations. In one of the few monly described as sharp, tingling, r,
unclear. For example, prevalence var- studies to specifically address non- shooting, and stabbing).29 The preva- d
ies with the sample stuclied: the clinic painfu l sensations after upper limb lence of phantom lin1b pain was 75% 5
versus community, inpatient versus amputation, Kooijman and associ- in another large sample of 478 ti
outpatient, lower limb versus upper ates30 reported the prevalence of non- community-dwelling adults with ac- d
limb. In addition, nonpainful phan- painful phantom sensations to be quired lower Limb an1putations.37 A i!
tom sensations have not always been 76% in a sample of 72 adults with ac- similar prevalence of phantom limb tl
well differentiated from phantom quired amputation. Similar to what pain was reported (69.2%) in a sam- cl
limb pain. 23•24 has been reported in adults with ple of 104 adults in Ireland with lower p
When distinguished, some esti- lower limb amputations, the sensa- limb amputations.35 S!
mates suggest that phantom limb sen- tions tended to be intermittent. Inter- It is important to note that preva- e
sations are experienced by virtually all estingly, the authors also reported lence estimates likely vary not only
amputees, 25 whereas others have re- that the risk of phantom sensations because different populations are \
F
ported high but somewhat lower rates was higher (a relative risk of 1.2) for studied (eg, clinic versus community) H
(eg, 80%).26 In one prospective study those experiencing residual limb pain but also because of how phantom
of nonpainfuJ phantom limb phe- than in those with no residual limb limh pain is defined. For instance, F
nomena, 90% of the 58 patients re- pain. No other factors were associated studies that ask amputees whether I!
ported phantom limb sensations at with phantom limb sensations in this they have "unrelenting phantom limb ~
some time during the 2-year group. pain" will likely show very different
follow-up period.27 Although the Little is known about the effect of prevalences from stuclies that ask am-
prevalence of these sensations did not chronic nonpain ful phantom limb putees whether they have had "any
decline over time, the frequency and sensations on the lives and function- phantom limb pain." We suspect that
duration of the sensations did. More ing of individuals who experience many of the studies in which phan-
recent cross-sectional research also them. Because by definition these tom limb pain was fow1d to be quite
suggests that nonpainful phantom sensations are not perceived as pain - prevalent included persons for whom c
sensations are common years after the ful, one might assume that they do phantom limb pain, although episod-
amputation. In a sample of 92 adults not negatively affect tl1e individuals ically present, was not problematic. s
with lower limb amputations, 80.4% who experience them. To our knowl- Thus, it is important for researchers
reported experiencing nonpainful edge, however, no studies have exam- not only to specify how phantom 1
phantom limb sensations in the ined this hypothesis. limb pain is defined but also to exam-
4 weeks preceding the study. 28 Time ine the prevalence of pain that is
from amputation did not correlate Phantom Limb Pain bothersome and clisabling, that is, the
with the occurrence of nonpainful One of the most commonly cliscussed proportion of persons who suffer as a
=
sensations (r 0.02); in fact, partici- consequences of amputations has result of phantom limb pain.
In addition to its prevalence, phan-
pants had lived with their amputation been phantom limb pain. Phantom
an average of 18 years (SD = 17.2, limb pain refers to painful sensations tom limb pain has been characterized
range of time from amputation = 1 to in the missing portion of the ampu- in terms of onset, frequency, dura-
53 years). Similarly, Ehde and associ- tated limb. Although earlier reports tion, intensity, and quality. 19 Onset of
ates29 reported that 79% of their suggested that the incidence of phantom limb pain is early, with sev-
community-dwelling sample of 255 chronic phantom limb pain was low, eral studjes suggesting that it develops
adults with lower limb amputations it is now thought that most amputees, within the first few days after the an:-
experienced nonpainful phantom possibly as many as 55% to 85%, ex- putation.19·26·38 Phantom limb pa!n
limb sensations. Similar to the study perience phantom limb pain from tends to be intermittent or episodic,

with only a few individuals reporting amputees. Given that upper limb am- peripheral input may trigger central
constant pain.28' 29 ' 32' 34•35 Using a pro- putation is less conunon than lower changes that result in differentiation
spective diary design uncommon in limb, few studies have specifically fo- pain.
the amputation literature, a British cused on phantom limb pain in indi-
study of 89 adults with phantom limb viduals who have lost an upper limb. Residual Limb Pain
pain after lower limb amputation re- A recent survey found that 41 o/o of a Until recently, less was known about
ported the episodic and variable na- sample of 99 adults with upper limb residual limb pain, although it was
ture of phantom limb pain.39 Study amputations had phantom limb generally believed that most residual
participants recorded, among other pain. 3 t In a sample of 72 adults in the limb pain resolved with wound heal-
things, the intensity of their pain ( us- Netherlands with upper limb ampu- ing. 25•32 This type of pain occurs in
ing a numeric rating scale) on an tations, mostly because of trauma, the portion of the amputated limb
hourly basis for 7 days. The investiga- Kooijman and associates30 reported that is still physically present. There is
tors found that 84% of participants that 51% had phantom limb pain, considerable discrepan cy in the re-
reported pain on each of the 7 study with 48% of those experiencing it ported prevalence of chronic residual
days, and 16% reported pain on 3 to daily. Age and time since amputation limb pain. For example, in their
5 days of the study period. In terms of were not associated with the phantom thoughtfuJ review of phantom limb
the frequency of episodes within a limb pain in their sample, although pain, Nikolajsen and Jensen 45 con-
day, 71% of participants reported ep- having sensations of a phantom limb tended that residual limb pain persists
isodes of phantom limb pain on more in only 5% to 10% of patients. This
was (relative risk = 11.3). Sixty-nine
than one occasion per day, and of contrasts starkly with several other
percent of a clinic sample of 76 pa-
these, 75% reported 4 to 5 episodes studies of adults with lower limb am-
tients with upper limb amputation re-
per day. Regarding duration of epi- putations. For example, 74% of a
ported phantom limb pain. 40 More
sodes, 80% of participants e:Kperi- conununity-dwelling sample of 255
research is needed on the prevalence
enced phantom limb pain for 6 to adults with lower limb amputations
of phantom limb pain as well as its
10 hours each day, with only 11 % re- had residual limb pain. 29 Similar rates
characteristics in those with upper
porting an average of 12 or more have been reported in other
limb amputation.
hours of phantom limb pain each day. community-based samples.28' 37 Other
A number of mechanisms, both
Typically, most patients describe studies report rates of 48% to
central and peripheral, have been hy-
phantom limb pain to be moderate in 56%.34•35 This variation in rates is
pothesized to explain the develop-
intensity, for example, an average pain likely affected by differences in study
ment of phantom limb pain. 22•25•41
intensity of 5 on a numeric rating populations (clinic versus conmm-
Although persistent peripheral nerve
scale of O to 10. 19•29•32 Through the nity) as well as methodology (defini-
use of hourly pain diaries, W11yte and discharges have been recorded after tion of residual limb pain). Longitu-
Niven 39 reported that the average in- amputation, 42 most evidence suggests dinal epidemiologic studies that
tensity across the 7-day study period a central abnormality in patients with clearly define residual limb pain are
ranged from 3 to 8 on a scale of O to phantom limb pain . Some authors needed to clarify the problem.
10 (mean = 4.5, SD = 4.6). Sixty per- have postulated, on the basis of clini- Similar to phantom limb pain, re-
cent of their sample reported average cal data, that hyperirritable foci de- sidual limb pain appears to be epi-
pain intensity in the lower half of the velop in the dorsal horn of the spinal sodic. Gallagher and associates 35
scale (3 to 4), and 40% reported pain cord after peripheral nerve transec- found that, of the 48% of their sample
intensity in the higher end (5 to 8). tion, possibly a result of the loss of of 104 patients who reported residual
These investigators also found great high-threshold input to the dorsal limb pain, 13% experienced an epi-
variation both among and within in- horn neurons. 25 ' 43 There may also be sode once or twice in the week preced-
dividuals in intensity, frequency, and more rostral central factors as well, ing the survey, 63% experienced an
duration of painful episodes. Patients because severe phantom limb pain episode more than twice, and 13% ex-
use various words to describe phan- has been reported to be unresponsive perienced constant residual limb pain.
tom limb pain. For example, it was to cordotomy2 5 and can also be un- Only 7% reported no residual limb
most commonly described as "squeez- masked by spinaJ anesthesia. 44 What- pain during the 1-week period (4%
ing," "burning," "knife like," and ever central changes exist, the initiat- did not specify). Other studies have
"throbbing" in one sample26 and as ing event in the development of also reported residual limb pain to be
"sharp," "tingling," "shooting;' and phantom limb pain is probably pe- intermittent. 19' 28•29 With the excep-
"stabbing" in another. 29 ripheral. It is thought that the massive tion of frequency and duration, other
Most of the research on phantom afferent barrage at the time of injury characteristics of residual Hmb pain
limb pain described thus far has been or amputation may est.ablish central have received considerably less atten-
conducted on samples mostly or processes that generate later pain, or tion in tl1e literature. When these fac-
completely consisting of lower limb alternatively, that the sudden loss of tors have been examined, studies sug-

gest that residual limb pain is typically and Branemark49 reported that 47% Neuromas
of moderate intensity for most, al- of their sample had back pain. These Every time a nerve is transected, the
though a notable subset (15% to 35%) rates are considerably higher than axons within the nerve will attempt to
describe it as severe.28•29 ' 46 In a study those reported in the general popula- regenerate and grow. For lacerations
by Gallagher and associates 35 residual tion, where it has been estimated that of nerves, this can be productive be-
limb pain was described as "distress- the point prevalence of back pain is cause if the nerve sheath (epineu-
ing" by 26% and as "horrible" or "ex- 15% to 25%.50 More important, the rium) is repaired in proper align-
cruciating" by 13% of their sample. existing studies suggest that back pain ment, the axons can grow down the
Chronic residual limb pain is also was significantly more bothersome to nerve and eventually reinnervate the
thought to be common after upper lower limb amputees28 and interfered distal limb. If there is no epineural
limb amputation, although less re- more with activities 51 than either sheath, as after an amputation, the ax-
search has been done in this popula- phantom Umb pain or residual Jjmb ons start to grow but tl1en stop after
tion. In one study, Kooijman and as- pain. It has been hypothesized that, forming an intertwined mass of scar
sociates30 reported that 48.6% of for some amputees, back pain results and nerve tissue, which can become
their sample of 72 Dutch adults with from altered gait patterns developed painful to pressure, stretching, and
upper limb amputations reported to accommodate a prosthesis; this hy- other types of physical manipulation.
chronic residual limb pain. In one of pothesis awaits experimental confir- This is called an amputation neu-
the few studies to focus exclusively on mation, however. In upper limb am- roma. Even when completely undis-
chronic pain following upper limb putees, biomechanical factors, such as turbed, electrical potentials may arise
amputation, 40 55% of the patients re- shoulder hiking and positional scolio- within the neuroma, causing negative
ported current residual limb pain, sis, may place them at risk for neck, local and distant sensory and motor
with 75% of those describing their shoulder, and back pain, although phenomena. These sensations can be
pain as intermittent and 25% as con- whether these changes lead to chronic bothersome and painful to the person
tinuous. pain remains unstudied. with limb loss.
In a transtibial amputation, five
Pain in Other Regions major nerves (tibial, superficial pero-
Other Sources of
Recent studies suggest that amputees neal, deep peroneal, saphenous, and
Pain experience pain in regions other than sural) and countless smaller sensory
In addition to phantom sensations the amputated limb and back. For ex- and fine motor branches are
and phantom pain, many other ample, Ehde and associates29 surveyed transected. Although surgeons have
souxces of pain and discomfort affect 255 amputees and found that pain oc- devised numerous techniques to min-
individuals with limb loss. Some of curred in locations other than the imize neuroma formation, none has
the more common problems include back, including the contralateral proved uniformly successful. The tra-
back pain and pain in other regions, sound leg or foot (43%), the ditional method applies longitudinal
neuromas, bone spurs, heterotopic buttocks/hips (37%), and the neck/ traction, divides the nerve simply, and
bone, chronic wounds/cysts, muscu- shoulders (3 1%). More than one third then allows it to retract. Other meth-
loskeletal overuse, and prosthesis- of this sample reported pain in three ods have included cauterization of the
related pain.47 or more locations. Forty-six percent nerve ends with chemicals or heat,
of a Swedish sample of transfemoral burying the nerve in bone or muscle,
Back Pain amputees (for nonvascular causes) re- encasing the nerve in impervious ma-
Although the focus of amputation ported pain in the sound limb. 44 In a terial, ligating the nerve, or injecting
pain research has primarily been on well-designed epidemiologic study of it with a variety of chemicals. Addi-
the amputated limb, back pain has re- outcomes of persons with traumatic tional methods include sewing the
cently been identified as a significant amputations, Pezzin and associates46 sectioned nerves to other nerves or
problem among lower limb amputees, reported that 16.9% of their sample sewing them back onto themselves,
affecting 71 % in an initial survey28 of patients with trauma-related am- thereby creating a nerve loop.
and 52% in a follow-up study in a dif- putations experienced severe pain in Because neuroma formation is in-
ferent sample.48 In both of these stud- the joints of the contralateral limb. evitable to some degree, the generally
ies, the reasons for amputation in- Thus, like many other groups with accepted method to correct the prob-
cluded trauma, vascular disease, disability, persons with limb loss may lem is still drawing the nerve distally,
congenital deficiencies, or cancer. In experience pain in multiple locations sectioning it, and allowing it to re-
an investigation of the health- related and from different causes (eg, phan- tract away from areas of press~r~,
quality of life of 97 adults with unilat- tom limb pain may be neuropathic; scarring, and pulsating vessels. Cli.nJ-
eral transfemoral amputations be- back or contralateral pain may be cal experience suggests that neuromas
cause of nonvascular causes, Hagberg musculoskeletal). that form in very scarred areas are the

most symptomatic. When working in forces and stress of walking several and 77% met lifetime criteria for, at
these areas, the surgeon should apply thousand steps per day. Although the least one psychiatric diagnosis. 52 Ma-
moderate tension to the nerve and tissues do accommodate and become jor depressive disorder, substance
section it cleanly, allowing it to retract more durable over time, they were abuse, and anxiety disorders were the
away from the site of amputation and never designed for this use; thus, they most commonly experienced disor-
into proximal soft tissues free of scar- naturally experience overuse wear and ders in this sample.
ring. This circumvents the problem of tear and cause some pain. In addition, Although many authors have spec-
the distal end of the nerve scarring to gait patterns may change, and overuse ulated that chronic pain negatively af-
the surgical site where traction and of the contralateral limb may occur. fects functioning and quality of life in
pressure are more likely. Traction on These are all potential sources of pain those with limb loss, only a few stud-
the nerve at the time of sectioning following lin1b loss. ies have examined this hypothesis. In
should not be excessive because too addition to a lack of research, the field
much tension can lead to proximal Prosthesis-Related Pain h as al so ten de d to riocus on only a 1ew c
pain and neuropathy. Knowledge of A prosthetic socket must be carefully outcomes and to use nonstandardized
prosthetic designs and regions or ar- constructed not only to fit the shape measures of functioning and quality
eas of contact and pressure will aid of the residual limb but also to apply of life, which make comparisons to
the surgeon in nerve placement. Thus pressure in areas that can tolerate it. It other populations, including the gen-
far, none of the other methods cited also must be designed to relieve and eral population, difficult. Thus, al-
above has been shown to lower the protect more sensitive areas. An exact though it is suspected that chronic
rate of symptomatic neuromas or mold of the residual limb does not pain likely contributes to suffering
1eganve1y- ar- me m~t,u emr 1m. n,e1~ve"¥t.1a'li ,hg~cu'"~ :5«1cp-.n1erns rliay" t:tlalige, awJ uvei u'St: lilaLe<f U1a1 t:nror
:he ~ >,,tC ~,vt" "ltLU\\J~"u~, i:roaa.13' ~~f, Qr~llliiu .{:,..,...+-.... h .............. : ........... : ....
lone Spurs and tomic regions or areas. The skilled loss, the nature and magnitude of this be
prosthetist modifies the socket by in- impact have not been quantified or son
leterotopic Bone, Chronic
Vounds and Cysts denting tolerant regions to increase adequately explored.
their share of the load, relieving other A few studies have included gen- five
\Then the bone is transected, a small areas. Inevitably, as a residual limb eral questions regarding the impact of :ro-
.ip of periosteum can ossify in to changes shape by normal maturation, chronic pain (typically phantom limb and
:,urs of bone, which can cause pres- muscle atrophy, or weight loss or pain). Gallagher and associates re- 35 ,ory
1re and pain when weight bearing in gain, the location and distribution of ported that phantom limb pain inter- are
1e prosthetic socket pushes tissues forces and loads change. The patient fered "quite a bit or a lot" for 11 % of 1ave
gainst the bone spurs. In individuals can experience severe local pain, their sample. Kooijman and associ- :iin-
rith trauma and burns, the damaged bru.ising, redness, blisters, or skin ul- ates30 reported that 64% of a sample has
rnscle can also form areas of hetero- ceration from these forces. of patients with upper limb amputa- tra-
)pic bone. Typically, this bone has a tions described suffering "moderately inal
ery irregular surface and edges and to very much" from phantom limb and
m cause undue pressure and pain. It Impact of pain; 60% of those with residual limb eth-
: usually diagnosed with plain radio- Amputation-Related pain reported suffering "moderately : the
raphs. Initial treatment consists of 46 1eat,
rosthetic modification to minimize
Pain on Functioning to very much." Pezzin and associates
scle,
reported that 24.4% of their sample
1e pressure in this area. If this ap- and Quality of Life of 78 persons with limb loss second- ma-
roach is unsuccessful, then resection Chronic pain is frequently accompa- ary to trauma reported severe prob- ;ting
f the bone spur or heterotopic bone nied by changes in physical, emo- lems with phantom limb pain in the .ddi-
: indicated. . tional, social, and vocational func- month before completing an inter- the
Small wounds, wh.ich can often tioning. For example, individuals with view; a severe problem was defined as s or
:art as inflamed hair follicles or chronic pain often experience changes being "extremely" or "very" bothered :lves,
,veat glands, can become chronic and in lifestyle, such as deconditioning by phantom limb pain in the past
ainful. and decreased participation in social month. s in-
activities. In the general population, Living with chronic pain caused by :rally
>veruse Musculoskeletal an amputation may also affect voca- ,rob-
chronic pain is also a major cause of
'ain unemployment because of pain- tional functioning. One study5 found 3 tally,
mputees have lost anatomic struc- related disability. Chronic pain has that, compared with employed ampu- ) re-
nes that were designed specifically also been associated with psychiatric tees, unemployed amputees reported sure,
>r interacting with the environment; disorders. For example, ln a sample of higher levels of pain and lower levels :lini-
fter amputation, the residual limb 200 adults with chronic low back of prosthesis use. Both phantom limb )mas
ssues are exposed to the tremendous pain, 59% had current symptoms of, pain and residual lin1b pain have been e the

negatively associated with return to sis) has been associated with a greater ling for pain intensity), as well as
work.s4.ss risk of chronic pain. 32 •60 Other bio- changes in pain interference and de-
Only a few studies have examined logic factors that have been examined pression (39% of the variance ac-
pain-related disability using standard- include level of amputation, amputa- counted for in both criteria after con-
ized measures. Marshall and associ- tion etiology, and comorbid medical trolling fo r pain intensity) . Higher
ates56 reported on the Sickness Im- problems. No consistent risk factors le:vels of catastrophizing predicted
pact Profile,57•58 a standardized have been found, however, and this poorer concurrent funct ioning, where-
measure of physical and psychosocial area requires further epidemiologic as lower levels of catastrophizing and
well being frequently used in the re- study. family solicitousness (eg, offers of as-
habilitation field. In this study, ampu- sistance, taking over a task) and
tees with high levels of pain showed Psychosocial Risk Factors higher levels of family support pre-
higher levels of overall disability Only a few studies have examined the dicted improvement in functioning
(physical and psychosocial) than did role of psychosocial factors such as over time. Catastrophizing was the
participants with lower levels of am- pain coping, cognitions, and social single most important predictor of
putation pain. In the first study using environmental variables in phantom pain, pain interference, and depressive
a standardized measure of pain- limb pain. In one study, Hill61 found symptoms in this sample. Thus, these
specific disability, the Chronic Pain strong associations between a mea- three studies are consistent with what
Grade, 59 nearly one fourth (23%) of sure of pain catastrophizing (having is known about adjustment in popu-
the subjects reported moderate to se- excessively negative and unrealistic lations where pain is the primary dis-
vere disability because of phantom thoughts about pain, such as "this ability: persons who think negatively
limb pain. 29 However, this study did pain is awful" or "I can't stand this") (catastrophize) about their pain show
not examine the disabWty associated and measures of both pain severity greater physical and psychosocial
with residual limb pain and was lim- and psychological distress (R = 0.50 dysfunction than those who do
ited to lower limb amputations. In and 0.51, respectively) . In a follow-up not.11 ,14,64
another study of 205 persons with study of phantom limb pain in 228
lower limb loss, the degree to which patients, Hill and associates 62 re-
pain interfered with activities varied ported that catastrophizing was again Chronic Pain in
with pain type. 51 That is, at the same significantly associated with pain se- Youth With
verity, physical disability, and psycho-
level, back pain interfered more sig- Amputations
nificantly with daily function than social dysfunction, accounting for an
additional 26%, 11 %, and 22% of the A 1993 review of phantom limb pain
phantom limb pain did after pain lev-
variance in these variables, respec- suggested that youth (ie, children and
els reached 5 or more on a pain inten-
tively, even after amputation-related adolescents) with limb loss or limb
sity scale of O to 10. To our knowl-
and demographic variables were con- deficiency may not experience chron-
ed ge, pain-related disability in upper
trolled. These two cross-sectional ic phantom limb pain.65 This conclu-
limb amputees has not been exam-
studies also showed that pain coping sion may have been premature, how-
ined.
strategies (eg, diverting attention ever, because there had been few, if
away from pain, increasing activity any, empirical tests of this assumption
Risk and levels) were significantly associated at that time. 66 More recent research
Biopsychosocial with adjustment to chronic phantom suggests that the prevalence of
Limb pain. Using a longitudinal study chronic phantom limb pain in youth
Factors design to test the utility of a biopsy- with acquired amputations is no less
67·69
Although a number of risk factors for chosocial model for understanding frequent than that for adults.
chronic pain have been identified in chronic phantom limb pain, Jensen Many questions remain regarding
the literature, less is known about the and associates 63 reported that pain chronic pa.in in youth with limb loss,
r isk factors fo r chronic pain following coping, pain cognitions, and social however. No studies have examined
limb loss. environmental variables predicted whether such youth experience pain
both concurrent (1 month after am- in other regions or what impact pain
Biological Risk Factors putation) and future (5 months later) may have on activities and participa-
Severe acute pain has been shown to functioning in a group of 61 lower tion.
be a major risk·factor for chronic post- limb amputees. Specifically, the inves-
amputation pain in several samples. 2 tigators found that psychosocial fac-
Within this category, the duration of tors contributed significantly to con-
Pain Management
pream putation limb pain of longer current pain interference and Clinical Assessment
than 1 month and more severe pain depression (28% and 46% additional A first and important step in the
(eg, burn injury, gangrene, thrombo- variance accounted for after control- treatment of chronic pain secondary

to limb loss is an accurate assessment mas. Care must be exercised because tional examinations of distal pulses
of the pain problem. This includes as- every transected nerve will form a and capillary refill of the toes cannot
sessment of the biologic, psychologi- neuroma, but not all neuromas will be done, the diagnosis. is more diffi-
cal, and environmental factors that be irritated and symptomatic. Be- cult. The proximal pulses and the tex-
contribute to nociception, pain, suf- cause MRI scans might reveal neuro- ture and temperature of the residual
fering, and pain behavior. 4 mas that are not necessarily symp- limb must be examined. Occasionally,
tomatic, the imaging study and tl1e prosthetic socket or suspension
Medical Assessment physical examination must be corre- system can induce venous congestion
The physician must conduct a com- lated to confirm that the pain is ema- or arterial occlusion with static or dy-
plete physical examination with an nating from the entrapped, scarred, namic use of the device. Patients with
open mind to the differential diagno- or irritated nerve end. Local nerve transtibial amputation, for example,
sis of musculoskeletal pain in patients compression can occur where the pero- may get popliteal compression only
with limb amputation. The proximal neal nerve wraps around the fibular when sitting, and the pain is relieved
nervous system is, unfortunately, the neck or where the ulnar nerve passes with standing, removal of the device,
easiest to overlook during this exami- behind the medial epicondyle of the or even simple release of a distal lock-
nation. The examination should in- elbow. The prosthetic socket can oc- ing mechanism.
clude tests for neurologic signs and casionally be a major contributor to
symptoms that may indicate radicular nerve irritation, and even with modi- Prosthetic and Orthotic
pain radiating from the neck or low fication of the socket, the irritated Assessment
back or nerve compression. Cervical nerve might remain symptomatic for
The general examination must also
stenosis, disk herniation, or thoracic some time.
include observation of gait in the
outlet syndrome can be present in an Mechanical pain from bone spurs
prosthetic device. With the patient
upper limb amputee who describes a or heterotopic bone can be suspected
standing, limb length equality and
change in severity of phantom pain. from the discomfort that accompa-
pelvic level are assessed. Improper
Likewise, lumbar disk herniation or nies tissue crepitus as tissue is moved
prosthesis length can lead to gait de-
spinal stenosis can present with pain over the end of the irregular bone
viations that may be in1proved with
or dysesthesia in an amputated foot. surface or compressed onto a bone
Traditionally, the physical examina- adjustment of the device. 70
spur. These suspicions can often be
tion attempts to identify focal supported by radiologic findings of Gait assessment also includes ob-
changes in motor units or changes in irregular bone in an area that directly servation of symmetry, balance, pro-
sensation in the hand or foot; in pa- correlates to the physical finding. Di- portion of time in the stance and
tients with amputated limbs, these agnostic imaging can be a mixed swing phases on each limb, and devi-
signs and symptoms might not be blessing. It is not unusual for radio- ations of the trunk, hips, knees, and
present in the physical examination. graphs to show irregular bone forma- feet. Some deviations may be related
Likewise, traditional nerve traction tion near the amputation site. Some- to prosthesis alignment and can be
tests, such as the straight leg raise test times it is asymptomatic, so it needs improved with changes in rotation,
for sciatic nerve irritation, are cer- to be correlated with physical findings varus, valgus, and translational posi-
tainly more difficult to perform and before intervention . Modification of tion of the foot. Chronic gait devia-
interpret in an individual with limb the prosthetic device is often tried tions may aggravate or contribute to
loss. first in an attempt to remove pressure back pain, although this assumption
The physical examination of the or transfer load from that a1·ea. Only has not been tested empirically.
amputation site itself is designed to if the physical exan1ination correlates As mentioned previously, if the pa-
identify for mechanical or local pain with the imaging study and nonsurgi- tient has localized pain, the prosthesis
that can be reproduced with direct cal treatment has failed should surgi- must be examined in that area to de-
palpation. Neuromas, local nerve cal excision be considered. termine whether the socket or sus-
compression, bone spurs, heterotopic Finally, ischemia from peripheral pension system might be causing un-
bone, muscle herniation, and muscle vascular disease may be causing clau- due pressure or irritation there. How
compression are all possible direct lo- dication or rest pain in the amputated the device contacts the body at rest,
cal causes of pain. Neuromas can oflimb. Typically, patients report that with sitting, and when moving must
ten be diagnosed by deep palpation of the pain ceases immediately when be considered. A device that appears
a nodule and Tinel's sign (tingling or they stop walking or when they re- to cause no local pressure may, in fact,
distinct reproduction of "electrical" move the prosthesis. If the pain began piston and cause repeated friction or
pain with tapping of the end of the after a change to a new type of socket irritation at a particular site during
nerve). or suspension system, fschemia must gait. With transfemoral amputation,
Imaging studies, specifically MRI, be considered. Once again, the physi- insufficient socket flexion may result
can assist in the diagnosis of neuro- cian must realize that, because tradi- in excessive lordosis during ambula-

tion as the patient compensates for answers (never and all the time). Re- spondents to rate how much pain has
this imbalance. An upper limb pros- spondents indicate their answer to the changed their ability to take part in
thesis that looks benign at rest can questions by making a mark across recreational, social, and fan1ily activi-
change contact areas and loading the line. The PEQ has been shown to ties (0 = no change, 10 = extreme
when it is used to carry a weight or be useful in assessing both chronic change). The third interference item
when it is used in a specific position pain and nonpainful phantom sensa- asks how much pain has changed
or activity. tions in adults with lower limb loss, 28 their ability to work (including
so it is a valuable clinical and research housework), using the same scale (0 =
Assessment of Pain tool. no change, 10 = extreme change).
Although only a few measures are The TAPES72 are a multidimen- The CPG then combines the inten-
specific to or include assessment of · sional self-report measure (54 items) sity items, disability days, and inter-
amputation pain (eg, Prosthesis Eval- designed to assess the experience of ference items to classify individuals
uation Questionnaire [PEQ),7 1 Trin- amputation and adjustment to a with pain into one of five grades:
ity Amputation and Prosthesis Expe- lower limb prosthesis. Like the PEQ, grade O (no pain problem), grade I
rience Scales [TAPES]72 ), a nwnber of it is not limited to measurement (low disability, low pain intensity),
good standardized measures of pain of pain. It assesses a number of di- grade II (low disability, high pain in-
are available in the chronic pain liter- mensions of the postamputation tensity), grade III (high disability that
ature. 4 We encourage the use of stan- experience, including psychosocial is moderately limiting), and grade IV
dardized instruments to assess pain adj ustment, activity restriction, and (high disability that is severely limit-
because such measul'es are reliable satisfaction with the prosthetic de- ing). In this scale, the term disability
and valid and allow populations to be vice. The TAPES tool specifically as- refers to pain-related disability and
compared. sesses the presence, frequency, dura- not to the disability associated with
To fully understand the pain expe- tion, and intensity of phantom limb actually having an amputation. This
rience, multiple dimensions of pain pain and residual Limb pain. It also measure has been useful in at least
should be assessed, including pain lo- asks respondents to rate the extent to one sample of persons with limb
cation, intensity, frequency, duration, which pain interferes with their daily loss 29 and has the advantage of being
affect, and pain-related disability. lives (not at all, a little bit, moder- brief while yielding information
Which din1ensions should be mea- ately, quite a bit, a lot). The TAPES about pain on several dimensions.
sured obviously depends on the pur- tool appears to have good internal
Thus, although not specific to
pose of the assessment. Whatever consistency and validity. 72 Like the amputation-related pain, it is a strong
meastues al'e chosen, we encourage PEQ, it is limited to persons with
candidate for clinical and research use
even the busiest of clinicians to ask lower limb amputations, so it merits
in the limb loss population.
not only about pain severity (inten- consideration as a clinical or research
One other measure that we think is
sity), location, and frequency but also tool.
particularly worthy of mention is the
about pain-related interference with The Chronic Pain Grade
Pain Interference Scale from the Brief
activities. (CPG) 60•73 is a simple, reliable, and
Pain Inventory (BPI).74 This scale
Several assessments, two specific to valid measme that has been used to
provides a broad-based assessment of
lower limb amputation and two gen- grade the severity of chronic pain in a
the impact of pain on a variety of ac-
eral measures, are available. The variety of pain populations. This
tivities, including sleep, work, self-
PEQ7 1 is a 43-item tool developed to measure consists of the following:
care, recreational activities, as well as
measure prosthesis function and ( l ) three ratings (present, worst, and
mood and relationships. It is a simple
quality of life of lower limb amputees. average) of pain intensity as described
assessment because it can be done
The PEQ comprises 10 scales that above; (2) a question concerning the
number of days in the past 3 months quickly and is easily self-
have been shown to have high inter-
nal consistency, temporal stability, that the respondent was kept from administered. As such, it is a poten-
content validity, and criterion valid- usual activities because of pain ("dis- tially valuable tool for examining the
ity. Although developed to measure ability days"); and (3) three interfer- impact of chronic pain on individuals
constructs other than pain, the PEQ ence items that ask how pain has in- with limb loss.
has 12 items that assess the frequency, terfered with daily activities, social
Assessment of
intensity, and "bothersomeness" of activities, and work over the past
nonpainful phantom sensations, 3 months. Th e first interference item Psychological Distress
phantom limb pain, residual limb asks respondents to rate how their Unfortunately, depressive disorders
pain, and back pain. To do this, it uses pain interferes with daily activities on are common among persons with
a visual analog scale that is a 100-mm a scale of O to 10 where O = no inter- chronic pain. Major depressive disor-
line bounded by two anchor phrases fe rence and 10 = unable to carry o ut der is a psychological disorder charac-
describing the extremes of possible activities. The second item asks re- terized by depressed mood or Joss of

TABLE 1 Measure and Scoring Instructions of the PHQ-9
Over th e last 2 w eeks, how often have you been bothered by any of More than Nearly
t he foll ow ing problems? Not at all Several days half the days every day
a. Little interest or pleasure in doing things 0 0 0 0
b. Feeling down, depressed, or hopeless 0 0 0 0
c. Trouble falling or staying asleep or sleeping too much 0 0 0 0
d. Feeling tired or having little energy 0 0 0 0
e. Poor appetite or overeating 0 0 0 0
f. Feeling bad about yourself-or that you are a fai lure or have let 0 0 0 0
yourself or your fam ily down
g. Trouble concent rating on t hings, such as read ing the newspaper O O O O
or watching television
h. Moving or speaking so slowly that other people could have O O O O
noticed? Or the opposite-being so fi dgety or restless that you
have been moving around a lot more than usual
i. Thoughts that you would be better off dead or of hurting yourself O O O O
in some way
Major depressive syndrome is indicated if answers to a or band five or more of a through i are at least "More than half the days"
(count i if present at all).
(Adapted from Spitzer Rl, Kroenke K, Williams JB: Validation and utility of a self-report version of PRIME-MD: The PHQ primary care
study. Primary care evaluation of mental disorders: Patient health questionnaire. JAMA 1999;282:1737-1 744.)
interest or pleasure that is not directly Psychological distress, including PHQ has been we!J accepted and per-
caused by a general medical condi- depression, is often underdiagnosed ceived to be useful by both patients
tion. It is associated with a variety of and undertreated. Because it may be and dinicians. 81 Thus, although the
emotional and physical symptoms, missed, depressive symptoms should clinical utility of this measure has not
such as weight loss or gain, insomnia be screened for and evaluated rou- been studied in the limb loss popula-
or hypersomnia, psychomotor retar- tinely by clinicians working with per- tion or clinic, its strong performance
dation or agitation, loss of energy and sons with limb loss. A number of in other medical settings suggests that
concentration, feelings of worthless- tools are available for use that are easy it warrants consideration for these
ness and hopelessness, and thoughts to administer and useful as initial patients.
of suicide or death.75 Emotional dis- screens.79 One that we particularly If substantial depressive symptoms
tress may also include subdinical lev- recommend is the Patient Health are detected, referral to a mental
els of depressive symptoms, anxiety, Questionnaire-9 (PHQ-9) 80 (Table 1). health provider can be made for a
psychosocial stress, and other mood The PHQ-9 is the 9-item depression more complete evaluation and for
complaints. screening scale from the larger Patient treatment. Aggressive treatment with
Health Questionnaire, a recently de- pharmacotherapy or psychotherapy
Approximately one third of per-
veloped measure for making criteria- should be considered. Depression has
sons who have chronic pain also ex-
based diagnoses of depressive and been shown to negatively affect phys-
perience a major depressive disor-
other mental disorders commonly en- ical, cognitive, social, and work func-
der.76 This is much higher than rates
countered in medical settings. 81 The tioning in other medical popula-
of depressive disorders in the general
PHQ-9 scale is half the length of most tions.82 Thus, treatment of depression
population (prevalence 3% to 9%) 75
other depression screens, has compa- has the potential not only to reduce
or primary care populations (preva- rable sensitivity and specificity, and suffering but also to minimize this
lence 10% to 15%).77 Among persons comprises the nine criteria upon additional disability.
with acquired amputation, the point which DSM-IV diagnoses of depres-
prevalence for depression appears to sive episodes are based. Thus, the Treatment of Chronic Pain
be somewhere between 25% and PHQ-9 can not only provide an index The treatment of pain in amputees
35%.78 Although less is known about of depressive symptom severity but bas received considerable attention in
rates of depression in persons with can also establish depressive disorder the literature, most of which is fo-
both acquired amputation and diagnoses. In addition to its good reli- cused on the treatment of phantom
chronic pain, it is probably safe to as- ability and validity, the l?HQ-9 is also limb pain. In his review of the history
sume that depression is a common easily self-administered, taking only a of treatments for phantom limb pain,
problem in this group. few minutes to complete. The larger Sherman 19 reported that more than

722 Section IV: Management Iss ues
60 different treatments have been have been positive,88 whereas other Pain Interventions
suggested, including a variety of studies have not shown any long-term
Given the limitations in the treatment
medical, surgical, psychological, and prophylactic effects.38•89·90 These
alternative options. For example, literature, we will briefly summarize
studies vary considerably in their
conventional treatments such as opi- the more common interventions for
methodologies, sample sizes, anesthe-
oids83 have been suggested, as have pain.
sia techniques, and reasons for ampu-
less conventional treatments such as tation, so it is too early to draw con- Pharmacologic
therapeutic touch 84 and electrocon- clusions about the efficacy of this
vulsive therapy.85 Unfortunately, the approach. More randomized clinical
Tricyclic antidepressants have long
success rates of these treatments have been used to treat phantom limb
trials are needed. pain. 19 Nevertheless, until recently, no
rarely exceeded the expected placebo Although there is a lack of con-
response rate of 25% to 30%. In ad- clinical trials evaluated their efficacy
trolled treatment studies for phantom for phantom limb pain. In a meta-
dition, most studies of the treatments
limb pain, we know even less about analysis of 39 controlled trials, antide-
for phantom limb pain suffer from
the types of treatment sought by per- pressa11ts were found to be beneficial
significant methodologic weaknesses;
sons with phantom limb pain or their in the treatment of a variety of types of
the published literature has consisted
perceptions of treatment. A few stud- chronic pain.93 None of the clinical
primarily of single-group designs,
clinical commentaries, and case studies have suggested that persons with trials included in this meta-analysis,
ies, with randomized clinical trials phantom limb pain may have diffi- however, focused on pain after limb
absent. culty accessing treatment for pain, loss. A number of studies have also
One exception was a randomized and even when they do, they find suggested that tricycl ic antidepres-
clinical trial of transcutaneous electri- such treatment unsatisfactory. For ex- sants are beneficial in treating painful
cal nerve stimulation, but it proved it ample, among 149 British veterans peripheral polyneuropatl1ies.94 Given
to be ineffective in treating chronic with amputations who discussed their that amputation often includes the
phantom limb pain.86 In addition, a phantom limb pain with their physi- severing of multiple peripheral nerves,
recently published randomized con- cian, 49 were told there was no treat- it is plausible that these medications
trolled trial found amitriptyline to be ment to help their pain and only 17 may be helpful in treating phantom
ineffective in treating chronic phan- were referred to a pain clinic. 34 In this limb pain. Nevertheless, only one ran-
tom and residual limb pai n in adu lts sam e study, the type of treatment that domized controlled trial has examined
with lower or upper limb amputa- was most frequently administered was the efficacy of tricyclic antidepressants
tions.87 Given the lack of controlled acetaminophen (53%) or an acetamin- for relieving chronic phantom limb
trials for postamputation pain, it is ophen/opioid combination (37%) . pain. In this randomized trial of 39
evident that we are far from establish- The only treatments that satisfied adults with chronic phantom limb
ing standards of care for managing pain and/or residual lin1b pain, ami-
more than half of the respondents
chronic phantom limb pain, and even triptyline was compared witl1 an active
were acetaminophen/opioid medica-
less is known about treating residual placebo (benztropine mesylate), and
tion, nonsteroidal anti-inflammatory 87
limb pain and other amputation- was found not to be efficacious.
drugs, and alcohol. Similarly, a study
related pain. More research is needed.
of 2,694 American veterans reported
One novel line of research is devel- Antiseizure drugs, which can beef-
that 54% of the sample had discussed
oping strategies to prevent chronic fective in calming excited nerves, have
phantom limb pain witl1 their physi-
phantom limb pain. Several studies been used for years to combat phan-
cian, but only 19% were offered treat-
have examined the use of periopera- tom limb pain, with gabapentin
ment.91 Only 8% of respondents re- emerging most recently as a first-line
tive epidural anesthesia provided at
the time of amputation. 38·88- 90 This ported being helped to any real extent medication. Clinical reports suggest
approach is based on the theory that by treatment. In another large study that these drugs may minimize the
phantom limb pain is, in part, medi- of 764 American veterans, the only number of episodes of phantom limb
ated centrally at the spinal cord at or treatments that reportedly produced pain, although this hypothesis has not
around the time of the amputation. It permanent effects were noninvasive been tested empirically. Recently, a
is thought that administering epidu- corrections of problems in the resid- crossover randomized controlled trial
ral anesthesia perioperatively m ay re- ual limb, such as desensitization.92 of gabapentin revealed tl,at it was ef-
duce the massive afferent discharge Short-term benefits were reported fective for some, but not all, patients
entering the central nervous system as from pain medications such as hyp- (DG Smith, MD, DM Ehde, MP
a result of preamputation disease or notics and analgesics. The authors Jensen, et al, unpublished data).
trauma, the amputation itself, and the concluded that most of the treat- Opiates and narcotics have been
immediate postoperative processes. ments surveyed were generally inef- used since ancient times to treat pain.
Results of at least one of the studies fective. Although we use narcotics extensively

around the time of surgery, we usu- Rehabilitation ment approaches are recommended.
ally try to avoid long-term use be- Interventions Unfortunately, amputation patients
cause, although they calm the reac- often do not have access to such mul-
At this time, there is no single cura-
tion to phantom limb pain, they do tidisciplinary services. •
tive treatment for chronic pain. For
not make it disappear. Unfortunately,
individuals whose chronic pain sig-
some patients may need a low level of
chronic narcotic therapy but typically
nificantly interferes with mood, func- Summary
tioning, and participation in activi- Pain following amputation remains a
only as a last resort, when other strat-
ties, rehabilitation is recommended. frequent and very bothersome issue
egies have not helped. Narcotics do
The most commonly accepted and for many individuals with limb loss.
not act at the source of the pain. In-
stead, they work in nerve centers and empirically supported approach in Phantom pain, ·phantom sensation,
the chronic pain literature is interdis- residual limb pain, back pain, neck
the brain. The pain is still there, but it
is not as bothersome. The opiate ciplinary and based on a biopsycho- pain, and general musculoskeletal
forms a cloud-like barrier that dimin- social model of chronic pain. Inter- overuse pain all occur. Pain also has
ishes pain signals being transmitted ventions grounded in this model many different characteristics, quali-
between the injury site and the brain, address the pathophysiologic pro- ties, and patterns and can present in
making the person more indifferent cesses as well as the psychological, so- various ways. Measuring and treating
to pain. Traditional narcotics have a cial, and behavioral factors that have pain is by no means straightforward
very fast onset and a high initial peak been associated with pain, distress, or routinely successful. Great strides
effect, but that effect wears off and pain-related disability. Treatment have been made over the last decades
quickly, and the pain recurs. As toler- goals typically involve modifying af- in our understanding of the different
ance for opiates increases, often more fective, behavioral, cognitive, and sen- types and sources of pain. We have
of the narcotic is needed to produce sory symptoms associated with the also advanced in our abiUty to define
the same effect, and it may be needed person's disability and suffering and, and m easure different types of pain.
more frequently. An array of safety ultin1ately, increasing the functioning Nonetheless, there is still much work
risks accompanies the use of narcot- of the person with pain. Treatment to be done. We simply cannot at this
ics, including decreased reaction time, goals may be met by participating in time eliminate or even minimize all
clouded judgment, and drnwsiness. In any of several rehabilitation therapies, types of pain. The scientific and med-
large doses, narcotics can inhibit res- including, but not limited to, physical ical communities realize that many
piration, making breathing difficult therapy, occupational therapy, voca- individuals suffer from chronic pain,
or even impossible. tional rehabilitation, and psychother- and we continue to seek new treat-
Newer, longer-acting narcotics lin- apy. For example, if a person is identi- ments to improve the quality of life
ger in a person's system for more ex- fied as using maladaptive coping for anyone who has pain.
tended periods. They do not have the strategies to deal with pain, such as The American Pain Foundation
rapid, high peak and fast wear-off of catastrophizing (thinking negatively), publishes the following Pain Care Bill
traditional opiates. Instead, they take he or she might participate in psycho- of Rights. 96 These are notable goals for
effect more slowly and maintain a therapy (group or individual) aimed all who treat pain to review and strive
steadier state. Such drugs do have dan- at decreasing negative thoughts about to achieve. This is what our patients
gers, however. Misuse of these newer pain and increasing reassuring, posi- hope for and expect from health care
drugs, such as oxycodone hydrochlo- tive thoughts. professionals.
ride, is increasingly common. On the Considerable evidence supports As a person with pain, you have
street, these drugs can be manipulated the efficacy of interdisciplinary pain the right to:
to remove their long-acting nature. programs in improving psychological • have your report of pain taken se-
This creates a tremendous dilemma and physical functioning when pain is riously and to be treated with dig-
for physicians and providers who must the primary disability, 9 5 although the nity and respect by doctors, nurses,
balance improving a person's life efficacy of such programs for persons pharmacists, and other healthcare
while minimizing the risk of abuse to with amputation-related pain is not professionals.
society. Some states limit the number known, nor is it known how often • have your pain tl1oroughly as-
of pills that can be dispensed in a sin- amputees participate in such rehabili- sessed and promptly treated.
gle prescription or closely scrutinize tation programs. We suspect that they • be informed by your healthcare
physicians who prescribe these drugs. commonly participate in only physi- provider about what may be caus-
Addiction risks, for both psychological cal therapy. For some, this may be ing your pain, possible treatments,
and physical dependencies, mean that sufficient. However, for those who are and the benefits, risks, and costs of
narcotics are not a path of treatment suffering and/or very disabled by each.
that we want to stay on for long, if we their amputation-related pain, more • participate actively in decisions
Venture onto it at all. comprehensive assessments and treat- abo1llt how to manage your pain.

• have your pain reassessed regu- 14. Boothby JL, et al: Coping with pain, in tom pain, resid ual limb pain, and
larly and your treatment adjusted if Gatchel RJ, Turk DC (eds): Psychoso- other regional pain after lower limb
your pain has not been eased. cial Factors in Pain. New York, NY, The ampu tation. Arch Phys Med Rehabil
• be referred to a pain specialist if Guilford Press, 1999, pp 343-359. 2000;8 l : l 039- 1044.
your pain persists. 15. Gatchel RJ, Turk DC, Dennis C (eds): 30. Kooijman CM, Dijkstra PU, Geer tzen
• get clear and prompt answers to Psychological Approaches to Pain Man- JH, Elzinga A, van der Schans CP:
your questions, take time to make agement: A Practitioner's Handbook. Phantom pai.n and phantom sensa-
New York, NY, T he Guilford Press, t ions in upper limb amputees: An epi-
decisions, and refuse a particular
1996, p 519. demiological study. Pain 2000;87:
type of treatment if you choose.
16. Loeser JD: What is chron ic pain? 33-41.
Theor Med 1991;12:213-225. 31. Dijkstra PU, et al: Phantom pain an.d
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55. Sheikh K: Return to work following of the length of lower-limb prosthesis ganization. Pain 2001;90:47-55.
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84. Leskowitz ED: Phantom limb pain 89. Jahangiri M, et al: Prevention of phan- 93. O nghena P, Van Houdenhove B:
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522-524. amor phine, clonidine and bupi- analysis of 39 placebo-controlled stud-
85. Rasmussen KG, Rummans TA: Elec- vacaine. Ann R Surg Engl 1994;76: ies. Pain l 992;49:205-2 19.
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297-301. Med 1983;62:227-238.

Psychological Adaptation to
Amputation
John C. Racy, MD
Introduction
Amputation represents a triple loss. It ciency adapt well, learning to use a spouse), financial constraints, and
involves loss of function, loss of sen- their remaining faculties in a com- occupational limitations may all com-
sation, and loss of body image. That pensatory manner. Children also plicate adjustment to the loss of the
so many patients adapt so well is at- adapt well to the loss of function, and limb. The correlation between age
tributable to their resilience and the they manipulate prostheses with great and the long-term emotional conse-
ingenuity and dedication of those dexterity. They are, however, particu- quences of amputation remains con-
who care for them. The experiences of larly sensitive to peer acceptance and troversial. Several early studies sug-
many such people, including the eight rejection.3 •6 Amputation in preadoles- gested that elderly amputees were at
members of a Tucson-area self-help cents or adolescents complicates is- greater risk for psychiatric distur-
group and patients at the University sues of emerging sexual identity. 7 For bances, such as depression, than were
of Arizona College of Medicine, have example, a 13-year-old member of the younger patients. More recent studies,
been incorporated into this chapter Tucson self-help group interviewed however, report just the opposite.9
(D Atkins, personal communication, for this report, when told that an am-
1984; S Kohl, personal communica- putation was necessary to treat the os- Personality Style
tion, 1984). teogenic sarcoma in her leg, reacted
Individuals who are narcissistically
with the statement, "No boy is going
invested in their physical appearance
to look at me."
Determinants of and strength tend to react negatively
In a sensitive review of amputation
to the loss of the limb. They see it as a
Psychological in teenagers, Lasoff 8 addressed two
areas that may lead to resistance to major assault upon their dignity and
Response care: autonomy and modesty. Lasoff self-worth. Conversely, dependent in-
The psychological response to ampu- recommended that resistance to care dividuals may cherish the role of pa-
tation is determined by many vari- be mitigated by allowing the teenager tient and find in it welcome relief
ables, which can be categorized as ei- to make as many decisions as possi- from pressure and responsibility.
ther psychosocial or medical.. These ble. Modesty is best protected by sen- Those with a history of depression
variables reflect the premorbid health sitivity of the health care team to the are more susceptible to dysphoria fol-
and the medical and surgical manage- patient's feelings when inspecting and lowing a.mputation. 4 The loss of a
ment of the amputee. examining the body. Among young limb serves to crystallize notions of a
adults, the response to limb loss de- basic defect, sometimes expressed in
Psychosocial Variables pends largely on its causes and the ex- self-punishing behaviors. 10
Age tent of disability and disfigurement.
In general, the greatest challenges for Because young adults enjoy the ad-
the young amputee are those relating vantages of an established identity, Portions of this chapter have been
to identity, sexuality, and social accep- physical resilience, and social confi- adapted with permission from Racy
tance. For the elderly, the greatest dence, these individuals tend to adapt JC: Psychological aspects of amputa-
tion, in Moore WS, Malone JM (eds):
challenges relate to livelihood, func- well to amputation. Lower Extremity Amputation. Philadel-
tional capacity, and relationships. 1• 5 Among the elderly, ill health, social phia, PA, WB Saunders, 1989.
Infants with a congenital limb defi- isolation (especially after the death of

Timid and self-conscious individu- (eg, site of amputation, time since Parents are the major source of
als who are excessively concerned amputation) influence coping to a support for children and adolescent
about their social standing are more lesser extent. 15 amputees. 7 •20 One study by Tebbi and
likely to suffer psychologically from In a study of 104 lower limb am- associates 21 emphasized the impor-
limb loss than are self-assured indi- pu tees, Gallagher and MacLachlan 16 tance of a supportive hospital staff for
viduals. 11 •12 Individuals tending to- found a similar correlation between the adolescent undergoing amputa-
ward a pessimistic or paranoid out- the discovery of a positive meaning in tion . But peer acceptance beyond the
look are Likely to feel that their worst the amputation and faci le adjust- family and hospital staff is critical in
expectations have been confirmed, ment. Specifically, they described the the successful adaptation of all ampu-
and their rehabilitation may be col- positive effect of "making favorable tees, especially children and adoles-
ored by much bitterness and resent- social comparisons [ie, comparing cents. The effect of traumatic ampu-
ment. Kolb and Brodie 13 reported oneself to those less fortunate], re- tation ·on the person's family is worth
that a rigid personality style may be evaluating the event as positive, rede- noting. In a sensitive case report,
associated with a greater risk of post- fining the amputation in one's life, White22 d escribed th e development of
operative complications, including finding side benefits, and imagining "hidden post-traumatic stress disor-
phantom pain, but a more recent lit- worse situations or forgetting nega- der" in the mother of a child who lost
erature review by Sherman and asso- tive aspects of their situation." both upper limbs secondary to elec-
ciates14 did not reveal any relationship trical injury. This affected her care of
between such a personality and phan- Economic and Vocational the child and her relationship to the
tom pain. Variables rest of the family.
Unexpected reactions may arise Individuals who earn their Hving
from secondary gain. If disability re- from motor skills that are lost with Medical Variables
sults in improved financial or social the amputation are especially vulner- Health
status, psychological adjustment may able to adverse reactions. T hose who Healthy young individuals who lose a
be easier. If the amputation brings have a wide range of skills or whose limb traumatically have many advan-
about the resolution of a conscious or main line of work is not particularly tages over older, frail individuals.
unconscious psychological conflict, dependent on the function of the lost Most amputees are elderly, in whom
the individual may indeed be happy limb may experience less emotional the surgery usually occurs after a pro-
that it occurred. difficulty. Of course, no am putee is longed period of treatment for pe-
completely insulated from discrimi- r ipheral vascular disease.3 •4 •23 These
Coping Strategies natory practices, subtle or otherwise, patients often have at least two other
Coping strategies can take several in the workplace, despite their prohi- comorbid medical disorders. These
forms and are a vital component of bition by federal law. Unemployment disorders are likely to limit restora-
the adjustment to amputation. Livneh is associated with a greater degree of tion of function and the return to an
and associates 15 suggested four basic psychological stress and may be a pre- active lifestyle.
categories: (1) active problem-solving, dictor of phantom pain. 17 Mental health problems can easily
including seeking support, reframing arise through a complicated series of
the event, and planning; (2) emotion- Psychosocial Support psychosomatic and somatopsychic re-
focusing, such as social withdrawal, All human beings require a support sponses to the loss. Shukla and associ-
wishful thinking, or self-blame; system throughout life to maintain ates24 studied 72 amputees prospec-
(3) problem disengagement, such as em otional health. However, not all are tively in India and found that nearly
turning to alcohol or drugs or to reli- so blessed, and many find themselves two thirds manifested postoperative
gion; and (4) cognitive disengage- in a transient or permanent state of psychiatric symptoms, the most com·
ment, or denial. As expected, active isolation. Single, widowed, and iso- mon of which was depression, fol-
problem-solving appears to be the lated individuals suffer more psycho- lowed by anxiety, crying spells, in-
most effective strategy. The other logical distress and difficulty in adapt- somnia, loss of appetite, and suicidal
strategies mentioned (emotion- ing to amputation than do those who ideation. In this regard, depression-
focusing, problem disengagement, are married or are actively connected with its attendant loss of energy, pes-
and cognitive disengagement) are to family or friends. Particularly help- simism, and psychomotor retarda-
more likely to be ass0.ciated with de- ful in the adjustment of the adult am- tion-may delay rehabilitation, a
pression, anxiety, and internalized and putee is the presence of a suppo rtive delay that in turn exerts a depressing
externalized hostility, and they there- partner who assumes a flexible ap- effect on the individual. Furthermore,
fore lead to an overall poorer level of proach, takes over functions when anger often underlies the d epressive
adjustment and acceptance. Sociode- needed, cuts back when the amputee is reaction. In a study of 46 amputees
mographic factors (eg, age, marital able to manage, and at all times sup- seen in London, Parkes l L found that
status) and disability-related factors ports the amputee's self-esteem. 18•19 among the 38 amputees who were

Chapter 57: Psychological Ad aptation to Amputation 729
thought to have some overall limita- the negligent or malicious behavior of the amputation. As Bradway and as-
tion of function attributable to psy- others is likely to produce persistent sociates30 noted, ''A poorly performed
chological origin, factors inculpated, feelings of resentment and self- amputation almost guarantees poor
in order of frequency, were depres- doubt.13 Litigation can easily compli- rehabilitation. Although a well-
sion, timidity, fear of further self- cate the process of psychological re- performed amputation does not guar-
injury, self-consciousness, Low intelli- habilitation and recovery. antee a successful rehabilitation out-
gence, senility, anger, resentment of come, it certainly makes successful
the need to rely on others, and sec- rehabilitation more possible."
ondary gain.
Preparation for the
Amputation
Reason for the Amputation Prosthetic
Individuals who have had adequate
Much of the earlier work on amputa- time to prepare for an amputation Rehabilitation
tion in the 20th century centered on fare better in the immediate postoper- The earlier a prosthesis is applied af-
wartime casualties.2' 13'25 The current ative period than those who do not ter amputation, the less the psycho-
situation in the United States is quite receive such preparation. Individuals
different in that amputations affect a logical distress observed. Conversely,
who are unprepared tend to react if application of the prosthesis is de-
much older age group and follow ei- negatively or with massive denial. It is
ther accidents or chronic illness layed or a prosthesis is not provided
not certain whether these differences at all, greater degrees of anxiety, sad-
rather than combat. The situation in persist, given that adaptation is ulti-
which the injury to the limb is sus- ness, and self-consciousness are
mately governed by many other vari- noted. The crucial elements appear to
tained during combat and leads to ables preceding and following the
evacuation, honorable discharge from be the integration of the prosthesis
an1putation. 30· 32 into the body image and the concen-
the service, and return to civilian life In general, the greater the loss, the
is not often seen today. 2 Adults who greater the difficulty in adjustment to
tration of attention on future func-
sustain a traumatic or accidental limb tion rather than on past loss.5 •30
the amputation. 12 There are, however,
loss tend to react with varying forms Extremes of age are by no means
instances of massive psychological re-
of denial and bravado.3·26 They are absolute contraindications for pros-
action to small physical losses such as
also more likely to experience symp- theses. Among the elderly, however,
the loss of a toe or a thumb as well as
toms of posttraumatic stJ·ess disor- preexisting illness may compound the
minimal reaction to the loss of several
der.27 Those who undergo an elective difficulties of adjusting to such de-
limbs. 33 Transhumeral amputation
amputation for the cure of a malig- vices. Elderly amputees with chronic
brings with it great anxiety and frus-
nancy benefit from the availability of obstructive pulmonary disease, for
tration, and bilateral tJ·anshumeral
time for preparation and exploration example, will already have compro-
amputation is perhaps the most diffi-
of alternatives. Not surprisingly, am- mised strength and endurance. None-
cult situation of all. In contrast, am-
putation appears easier to accept theless, they deserve a trial period of
putation of one leg below the knee al-
when the affected body part is the site rehabilitation with a prosthesis, albeit
lows relatively good adjustment, with
of a malignant lesion or is a source of
restoration of both function and body under close supervision.35
substantial pain or hindrance to nor-
image.12 In a study comparing ampu-
mal functioning. 28 The reaction is
tation and limb salvage in the treat- The Team Approach
usually one of realistic acceptance and
ment of extremity sarcoma, there
cooperation with the treatment Adaptation to amputation is a multi-
were surprisingly no significant dif-
team.3·29 Such individuals seem to faceted and evolving process requir-
ferences in psychological response
make an excellent adjustment, assum-
and functioning between the two ing different kinds of _attention at
ing of course that the malignancy has
been cured and the pain has been re- groups. 34 each stage. Thus, the team approach
has emerged as the standard approach
lieved.
to rehab ili ta tio n. 3•18•28•30•36.41
For the elderly, surgery usually oc- Surgical Having a wide range of skills and
curs after a long period of suffering
Comp I ications approaches represented on the reha-
resulting from diabetes mellitus and
peripheral vascular disease. Most ac- Individuals witl1 postoperative pain bilitation team increases the probabil-
cept the surgery with relief because it or infection or who require residual ity that all aspects of rehabilitation
often signals the end of suffering and limb revision tend to develop despair will be addressed and none over-
the return to improved functioning . and withdrawal to a greater degree looked. The team may include mem-
Some react indifferently or negatively than those who do not. 11 This obser- bers of the amputee's family as well as
and view the surgery as proof of fail- vation highlights the importance of amputees who have been successfully
ure. 3·29 Amputation necessitated by surgical skill in the performance of treated. Self-help groups for amputees

are extensions of the team ap- function, loss of income, pain, diffi- A useful part of preoperative prep-
proach.42,43 culty in adapting to a prosthesis, cost aration is talking with an age-
of ongoing treatment, and disposal of matched amputee. One physician told
the limb. The second group of con- of an adolescent girl who spoke with a
Vocational
cerns are more symbolic, such as boy of similar age who had previously
Rehabilitation changes in appearance, losses in sex- undergone the same procedure. He
Restoration of the capability for gain- ual intimacy, and perception by oth- stated, "The boy told her about his ex-
ful employment is an integral part of ers. Most individuals informed of the perience and took off his prosthesis to
successful rehabilitation. Kohl 18 notes need for amputation go through the show her how it worked. She, thereaf-
that amputees may regard unemploy- early stages of a grief reaction, which ter was much more amenable to the
ment as a "deniaJ of their 'right' to may not be completed until well after opera~on and to rehabilitation; she
participate in the family's decision- their discharge from the hospital. saw that she was not alone in having
making processes" and says that "the Dise-Lewis 10 suggests that the death to face the specific problem." 28
success of rehabilitation efforts and dying paradigm may be applied Group members who received ade-
should not only be measured by re- to the impending loss of a body part, quate preparation before the surgery
turn to income-producing work, but a loss that may threaten the amputee's indicated that the preparation con-
rather the return to the person of his core identity. One young patient, for tributed to their peace of mind after
decision-making abilities to choose example, found significant relief of the event. The process of acceptance,
the lifestyle that would be most ful- preoperative anxiety by writing a however, required time and effort.
filling to him." farewell letter to her leg, much like One member of the group described
addressing the loss of a loved one.28 her reaction as one of ambivalence
The manner in which the surgery and oscillation. She switched repeat-
Stages of Adaptation is presented by the surgeon can have edly from acknowledging that the
The psychological reactions to ampu- much bearing on the magnitude and amputation was expected and even
tation are clearly diverse, ranging kind of affective response. Mendelson desirable, to having feelings of great
from severe disability at one extreme and associates40 recommended that fea r and dread. "Like a ghost in my
to a determined and effective resump- the surgeon paint a realistic picture of closet," she said, "I took it out now
tion of a full and active life at the oth- the immediate and long- term goals and then to scare myself with it:'
er.44 In general, the process of adapta- for the patient and the family. Label-
tion can be viewed as occurring in ing the amputation as a reconstruc- Immediate Post operat ive
four stages: the preoperative stage, the tive prel ude to an improved life is Stage
immediate postoperative stage, in- much different from implying that it The period between the surgery and
hospitaJ rehabilitation, and at-home is a mutilation and a failure. Further- the start of rehabilitation may last a
rehabilitation. ,s,3o,34A5 •48 With the more, a hopeful attitude, a detailed matter of hours or days, depending,
exception of the clearly demarcated explanation of all aspects of the sur- among other things, on the reason for
preoperative and postoperative stages, gery and the rehabilitative process, the amputation, the extent and condi-
most adjustment occurs along a grad- and a full response to all questions tion of the residual limb, and the kind
ual continuum. A division into four (especially those that seem trivial) ap- of rehabilitation thought to be feasi-
stages, however, allows for the high- pear to diminish anxiety, anger, and ble. Psychological reactions noted in
lighting of issues that arise most crit- despair. this phase are concerns about safety,
ically at each point in time. Several members of the self-help fear of complications and pain, and,
group interviewed for this report elo- in some instances, loss of alertness
Preoperative Stage quently described the consequences and orientation.31 In general, patients
In amputees who have ample oppor- of failed communication. One who who undergo an amputation after a
tunity to be prepared for surgery, ap- regarded her impending amputation period of preparation react more pos-
proximately one third to one half wel- as "losing a member of my family" felt itively than those who sustain it sud-
come the amputation as a signal that scared "out of my wits" and was re- denly, after assault or accident. Most
suffering will be relieved and a new peatedly "horrified." She reported that individuals are, to a certain degree,
phase of adjustment can begin. Along her surgeon had described her as his numb, partly as a result of the anes-
with this acceptance, there may be "failure" and told her very little about thesia and partly as a way of handling
varying degrees of anxiety and con- the details of the surgery and the pro- the trauma of loss. For those who
cern. Such concerns fall into two cess beyond. Another, when informed have suffered considerable pain be-
main groups. Perhaps for most per- that she would lose her leg, reacted fore the smgery, the amputation may
sons, the more important issues are with the thought, "They might as well bring much-needed relief. This was
practical ones such as the loss of take off my head." true for four of the eight members of

Chapter 57: Psychological Adaptation to Amputation 731
the self-help group interviewed for depression was correlated signifi- ization," with attendant sadness and
this report. cantly with an increase in functional grief.52 Varying degrees of regressive
ability, suggesting that increasing behavior may be evident, such as a re-
In-Hospital Rehabilitation functional ability may be one of the luctance to give up the role of being a
In-hospital rehabilitation, in many most important factors in postampu- patient, a tendency to lean on others
ways, is the most critical phase and tation rehabilitation with regard to beyond what is justified by the dis-
presents the greatest challenges to the depression. ability, and a retreat to "baby talk." 53
patient, the family, and the rehabilita- Factors that facilitate adjustment Some resent any pressure put upon
tion team. It calls for a flexible ap- and rehabilitation in this phase are them to resume normal functioning.
proach addressed to the rapidly evolv- early prosthetic fitting, acceptance of Others may go to the oilier extreme
ing needs of the individual. Initially, the amputation and the prosthesis and vehemently reject any suggestion
the patient is concerned about safety, by fam ily and friends, and introduc- that they might be d isabled or require
pain, and disfigurement. Later, the tion of a successfully rehabilitated help in any way. An excessive show of
emphasis shifts to social reintegration amputee to the recovering pa- sympathy generally fosters the notion
and vocational adjustment. 3•18 In this tient.3,18,31,39,40,4S,s 1 Almost all the that one is to be pitied. In this phase,
phase, some individuals experience members of ilie group interviewed for three areas of concern come to the
and express various kinds of denial tl1is report agreed that early pros- fore: return to gainful employment,
shown through bravado and competi- thetic introduction was of the highest social acceptance, and sexual adjust-
tiveness. A few resort to hwnor and importance. Two women who sus- ment. Of immense value in all of
m1mm1zation. They might make tained transtibial amputations re- these matters is the availability of a
wisecrc!,cks such as, "You see more ported that awakening to find that relative or a significant other who can
when you walk slowly." Mild euphoric they had two "legs" in bed was most provide support without damaging
states may be reflected in increased reassuring. The 13-year-old girl de- self-esteem. 3 1•32
motor activity, racing through the lighted in throwing back the bed- The mother of the young man who
corridors in wheelchairs, and talking clothes and flaunting her artificial leg lost his arm as the result of an electri-
excessively. 26 to her adolescent visitors. Those who cal injury spoke of the profound
Eventually, sadness sets in. The did not, for one reason or another, change t hat occurred in his behavior
grief response to lin1b loss is probably obtain a prosthesis looked forward to on his return home. He regressed to
universal and time limited.4 •44•49 it and often fantasized about it. One the point that she felt that she "had
Parkes 29 describes the response as young man who lost his arm at ilie another baby in the house." The
similar to that seen in widows. He high transhumeral level as a result of young mother who lost her hand in
lists four phases: ( 1) "numbness," in an electrical injury dreamed of be- the paper shredder was concerned
which outside stimuli are shut out or coming a "bionic man." that people would look at her as
denied, (2) "pining" for what is lost, Sadness, although keenly felt, may tho ugh she were a "freak." She found
(3) disorganization, in which all hope be concealed. A young mother who her anxiety greatly relieved when both
of recovering the lost part is given up, lost her hand in a paper shredder her children and their schoolmates
and (4) reorganization. The degree tried to put on a happy face for her took her amputation in stride and
and rate at which individuals go family. "Sometimes," she said, "we asked about it matter-of-factly. A
through these four phases varies from have to joke so that people a.round us middle-aged woman who underwent
individual to individual, and indeed, can deal with it." an amputation after a prolonged pe-
the process often lasts well beyond the riod of disability resulting from po-
period of in -hospital rehabilitation. At-Home Rehabilitation liomyelitis found herself one d ay fac-
During this time, some patients expe- The amputee's return home can be a ing a sink full of dishes and a request
rience phantom lin1b sensations and particularly taxing period because of from her husband that she wash
phantom pain, wbkh are discussed loss of the familiar surroundings of them. She did so with tears running
later. the hospital, and attenuation of the down her face and thoughts run ning
Depression of varying severity has guidance and support provided by through her mind of her husband as
been shown to affect approximately the rehabilitation team. Thus the at- cruel and mean. Later, she recognized
40% of amputees. 12 Schubert and as- titude of the family becomes a major that it was "the best thing that he
sociates50 observed a decrease in de- determinant of the amputee's adap- could have done for me" and was
pression during in-patient hospital tation. Family members should be rather amused to learn that the sce-
rehabilitation and attr ibute the de- involved in all phases of the rehabili- nario was contrived by her surgeon
11 40
crease to "diminishing life crises ef- tative process. ' and her husband to encourage her in-
fects, increased functional ability, gen- During this phase, the fuJ! impact dependence. Equally helpful to her
eral psychotherapeutic milieu effects, of the loss becomes evident. Some in- was her children's startled response
and nonspecific effects." A decrease in dividuals experience a "second real- on learning that their mother was re-

ce1V1ng disability benefits. To t hem, surgery. Many amputees, however, Sherman and associates 58 •59 argue
she did not seem to be disabled at all contin ue to have occasional e:Kperi- that most amputees eKperience phan-
and therefore did not need benefits. ences of itching or movement, some- tom limb pain to varying degrees and
In fact, they were interested in the times after residual limb stimulation. that it is probably a complex form
prosthesis and expressed the wish that Though rare, phantom limb sensation of referred pain with a physiologic
perhaps they too could don and re- has been reported in both children rather than a psychological etiology.
move their limbs when they grew up. and adults with congenital limb defi- Pinzur54 regards phantom limb pain
The group members were unani- ciencies and in those who sustain the as a variant of sympathetic dystrophy.
mous in rejecting the "handicapped" limb loss at a very early age. 55•57 In Preamputation pain has been shown
label, and each thought that his or her general, phantom limb sensations to increase the incidence of phantom
affliction was lighter than those of the present no particular problem. All limb pain and residual limb pain.60
others. One of them said, "Most well- members of the self-help group bad There is general agreement that phan-
adjusted people prefer to accept what experienced them at one time or antom limb pain and life stresses are re-
happened to them" and thus "would other. Even 10 or 15 years after lated. In a study of 24 male amputees,
not trade with another amputee." AJl amputation, some of them still expe- Arena and associates 53 observed an
conceded that the adaptation would rienced an intermittent itch that, curi- isomorphic pain-stress relationship,
have been immensely more difficult ously, was relieved by scratching the namely, a roughly contemporaneous
without the active support of their prosthesis. increase in phantom limb pain with
families. increased stress and vice versa. The
A subtle, but often overlooked, is- Phantom Limb Pain typical psychological profile of the
sue is the ease with which the disabil- Pain experienced in the missing limb amputee suffering phantom limb pain
ity can be concealed in social settings. is a much more serious issue than does not differ from that of the gen-
One group member, for example, re- eral population of chronic pain suf-
phantom limb sensations. At the Uni-
marked that one advru1tage of a leg ferers. 14 Thus, phantom limb pain,
versity of Arizona, persistent phan-
amputation over an upper limb loss which can be serious and disabling,
tom limb pain has been reported by
was that it could escape detection in remains incompletely understood, but
fewer than 2% of amputees. 5
such settings. approaches the model of a chronic
Early work on phantom pain led to
Not surprisingly, amputees able to pain syndrome with evidence of
the assumption that antecedent and
resume a full and productive life tend physiologic and psychological com-
concurrent medical states as well as
to fare best; this is much easier for ponents.
psychological factors combined to ex-
those with marketable skills who sus- In the self-help group, only one
plain its existence. In the series of
tain the amputation while still in vig- member reported persistent phantom
2,284 amputees studied by Ewalt and
orous health. For elderly amputees limb pain accompanied by residual
associates2 5 at the end of World War limb pain. He underwent long and
who have limited skills, particularly if II, phantom limb pain was extremely
they have other medical disorders, the complicated procedures after the ini-
rare and was noted in individuals who tial amputation, all designed to relieve
probability of a full return to an ac- also showed psychopathology. These his phantom pain. These included
tive life is considerably dinunished. investigators wrote that pain "tended
Acceptance of a new, more leisurely nerve stimulation, acupuncture, re-
to come and to go with psychopatho- sidual limb revision, and even spi nal
way of living with reduced responsi- logical symptoms, irrespective of block. At the time of the interview, bis
bility and pressure to be productive what type of eKternal treatment was only relief came from the use of oxy-
can partially or fully balance the loss carried on.» codone on a regular basis. So dis-
of function in older amputees. 31 Parkes 17 found that phantom limb tressed was he by his pain that he had
pain could be predicted by certain repeatedly entertained the fantasy of
Special Areas of immediate postoperative phenomena taking a gun ru1d shooting his "leg"
such as the presence of residual limb off to rid himself of it. Other mem-
Concern pain, prior illness of more than I year bers eKperienced fleeting episodes of
Phantom Limb Sensations duration, the development of residual pain described as a sensation like an
The feeling that the amputated limb limb complications, and, interest- electric shock or, as one put it, "like
is present and moving is so common ingly, other factors not related to sur- putting your finger in a 220 [volt]
as to be regarded as a universal occur- gery, such as continued unemploy- outlet." A few described cramping
rence after sw·gery. 13•1 7 •30 •54 Phantom ment and a rigid personality. Some sensations and feelings of constriction
limb sensations tend to abate rapidly, amputees eKperience phantom limb that diminished over time. Two men-
however, so only a few individuals pain in association with micturition, tioned aching when the weather
continue to perceive their limbs as climatic changes, and emotionally changed and rain was approaching.
still present and active 1 year after disturbing events. 13 Several members of the group sponta-

neously volm1teered the view that the ceptance of the new body image, all of to be faced by each of them. Most re-
support of the family members was of them continued to experience self- ported success in facing it, mainly be-
great help in reducing phantom pain consciousness in social situations. For cause of the supportive response of
when it occurred. example, they tended to walk m ore the partner. Yet, despite verbal and
clumsily when they felt observed by behavioral reassmance of the partner,
Body Image other people in public. Members of several patients spoke of lingering dif-
Amputation requires a rev1S1on of the group described a pool party ficulty in seeing themselves as ade-
body image. Dreams and the draw-a- hosted by them to which they had quate sexual partners rather than as
person test can indicate perceptions invited their friends and relatives. repulsive sexual "freaks." As one
about body image. Amputees who However, the only people who actu- group member put it, "There is still a
adapt well draw a person with a fore- ally went into the pool were the non- small part that doesn't accept." The
shortened limb or without any limb amputees. passage of time appears to aid in this
at all; those who adapt poorly draw adjustment. One member stated that
the missing limb larger than the op- Sexuality 15 years after the event, her missing
posite limb or with increased mark- Sexuality is an area of some anxiety for limb was "a nonissue" in the sexual
ings.33 Similarly, dreams that incor- most amputees, especially those who sense. T his was not the case for the
porate the prosthesis or do not are young.7 •10 • 18•63 Concern arises 13-year-old girl who had expressed
particularly dwell on the missing part from the following sources: (1) fear the concern that no boy would ever
are consistent with a more positive that the body will not be accepted by look at her. She lived for 2 years after
adaptation. In one prospective study the partner, (2) self-coJ1Sciousness, the surgery but did not have occasion
of 67 patients who had suffered severe (3) the loss of a functioning body part to go out on a date. She maintained
hand trauma, much of the dreaming such as tlle hand, and (4) the loss of an the hope tl1at one day she would do
included nightmares of further injury area of sensation. so and was greatly comforted by her
or incapacity.61 However, the fre- A prostllesis can provide func- brother-in-law, who told her that her
quency of such nightmares decreased tional restoration and some return to amputation would "weed out the
significantly about 1 month postoper- normal appearance in most situa- creeps."
atively. It has been suggested that the tions, but it is absolutely of no use in
amputee, in a sense, must contend the terms of sexuality. A comparison
with three body images: intact, ampu- with the sexual experience of para- Management of the
tated, and with prosthesis. Individuals plegics is instructive. Those who suf- Amputee
who are unable to accept the last two fer paralysis often enjo-y preserved
are likely to reject the prosthesis and sensation in the affected part and Based on research and the personal
to experience difficulty in functional continue to see their body as intact. experiences of amputees reported
and social adjustments. Related to the They may also entertain hope of a re- here, several conclusions can be
issue of revised body image is concern turn of function in the affected part. drawn regarding effective approaches
with social appearances and accep- T he amputee enjoys none of these to tlle management of the amputee.
tance by others. Even when consider- advantages. The self-help group referred to in this
able success is achieved in functional A recent study of lower limb am- chapter agreed unanimously with the
restoration, there often remains some putees showed that even though most following management approaches.
shyness about revealing the ampu- patients experienced difficulties in The strategies fall roughly into six ar-
tated body to others. Social discom- the areas of sexual ar o Ltsal, sexual eas: preparation, surgical technique,
fort related to the amputation has behavior, and orgasm, more than early prosthetic fitting and mobiliza-
been associated with the development 90% reported a high int ei est in sex.64 tion, tl1e team approach, vocational
of depression. 62 The investigators could not attribu te and activity rehabilitation, and special
The m embers of the group con- the disparity between s~ual activity approaches such as group support
firmed these observations and saw a and sexual interest to anxiety or and psychotherapy.
connection between accepting one's depression .
new bodily configuration and accept- With the many concerns and chal-
Preparation
ing a prosthesis. One viewed her body lenges facing the amputee, the reha- Although it is hard to prove stat1st1-
more positively after am putation be- bilitation team must be careful not to cally that preparation has a bearing
cause her prosthetic leg worked better overlook sexual issues. Successful re- on ultimate outcome,30·31 common
than the leg that she had lost. Most sumption of sexual activity may re- sense, clinical observation, and the re-
had come to regard their prosthesis quire the learning and practice of new ports of amputees all suggest that
as part of themselves, at times re- sexual behaviors.65 The members of proper preparation is highly desir-
vealed in dreams. Nonetheless, despite the self-help group agreed that sexu- able.4·18•32·39·40 Ferrari and associ-
their successful adaptation and ac- ality was an important issue that had ates28 have fou nd it beneficial to

broach the subject of amputation error to relegate this procedure to in- the patient's needs. As tl1ese needs
with children no more than 2 to 3 experienced hands. As Bradway and evolve, flexibility and adaptation to
days before the surgery because they associates 30 indicate, "In om pro- new realities are required not only of
feel that discussing the procedure too gram, the senior surgical attending amputees, but of those who help
far in advance "can cause anguish and physician is directly involved in the them. To the extent possible, the in-
be intolerable to people so young." performance of all amputations and volvement of members of the family
Preparation must include a clear ex- supervises the entire process of am- at all of these stages can be of tremen-
planation of the reasons for the amputation rehabilitation." dous help.40 Perhaps the most valu-
putation, the viable alternatives, if able contribution of the team ap-
any, the exact surgical procedw·e, and Early Prosthetic Fitting and proach is the facilitation of a more
the postoperative rehabilitative pro- Mobilization rapid return to familiar suxrotmdings
cesses. Anticipating and dealing with There is little doubt that tlle earlier and to independence. The prospective
the various issues that patients will the prosthesis is applied, the better study by Ham and associates 36 of 223
face, even if these are not raised by amputees found that team manage-
the results are in terms of functional
the patients themselves, is of great ment reduced hospital stays signifi-
capacity and psychological adapta-
help. Such issues include disposal of tion.5'31 As Bradway and associates 30 cantly and increased the long-term ef-
the limb, relationship with friends fectiveness of rehabilitation. No less
describe, "Early prosthetic fitting and
and family, degree of loss and return important, as Dise-Lewis 10 indicated,
rehabilitation enable the patient to
of function, work capability, costs of is the role of the team in validating
incorporate all of his physical and
surgery and rehabilitation, sexual ad- the amputee's right to be in control of
emotional efforts into recovery from
justment, and social impact. Among his or her own rehabilitation and in
the earliest possible moment, rather
patients in whom disease is the reason
than allowing the patient to focus providing a safe haven for emotional
for the amputation, many fear a re-
only on disabilities and pain." Intro- expression.
lapse or a worsening of the course of
ducing the patient to a successfuUy re-
the disease. This feeling of ever- Vocational and Activity
present dread is called the sword of habilitated amputee may be of great
assistance in this effort.52 Of para- Rehabilitation
Damocles syndrome because the
missing limb is a constant reminder mount importance to patients, and No approach to amputation can be
of the disease. 28 perhaps a predictor of prosthetic use, considered successful withou t some
The amputation should be pre- is tlle comfort and usefulness of the resolution of the issue presented by
sented as a desirable lifesaving or device. 6 7 The level of the amputation the loss of skills, job, and livelihood.
life-improving option, rather than as also seems to be a significant determi- Even in the absence of pressing finan-
a last resort or an indication of fail - nant in the ultimate use of appliances. cial need, the loss of earning capacity
ure. Indeed, the patient's quality of Sturup and associates68 observed a may entail a profotmd loss of self-
life is sometimes better after an greater rate of prosthetic use among esteem, which brings with it a variety
amputation than witl1 limb-sparing transradiaJ amputees than among of adverse psychological phenomena.
treatrnents. 37•66 The term reconstruc- transhurneral amputees and a clear It is not essential that the person re-
tive surgery is preferable to amputa- tendency toward non use of a prosthe- sume work, but it is essential that the
tion and these terms can both be used sis among younger amputees and person accept whatever new role and
to describe the procedure. those with an amputation of the non- capacity can now be enjoyed. 18 This
Much of the preoperative prepara- dominant arm. Durnnce and O'Shea67 issue should be approached with an
tion should be conducted by the op- reported that amputees are least likely open mind. Some amputees prefer re-
erating surgeon. Although the infor- to use prostheses during leisw·e activ- turning to employment, witl1 all the
mation is widely available and may be ities. security, stimulation, and structure
imparted by any member of the team, that it presents. Others, thanks to per-
no other person can communicate The Team Approach sonal wealth or to disability and re-
witl1 the degree of authority and con- A team approach is optimal for the tirement benefits, may choose not to
fidence needed by patients as they rehabilitation of amputees and be employed. As Kohl 18 wrote, "It is
contemplate the imminent loss. should include the surgeon, surgical important that there be not a judg-
nurses, prostlletist, physical therapist, mental response from the staff toward
Surgical Technique occupational tl1erapist, social worker, those patients who do not seek paid
Obviously, good surgical technique is vocational counselor, and, if indi- employment."
of the essence. Perhaps Jess obvious is cated, a psychiatrist or psycholo- Several investigators have at-
tlle need for the senior surgeon to gist. 3 ,1 8, 19,30,37,38,40,4S With a team tempted to find predictors of success
perform the surgery or to be involved with a variety of skills, each member in the rehabilitation of amputees. Pin-
intimately in its performance. It is an can address one particular aspect of zur and associates 45 suggested that

psychological testing using standard derstand that the various stages of control pain. Neither psychotherapy
personality inventories and measures grief described by Parkes 11.29 and oth- nor psychoactive medicine appears to
of cognitive abilities may be helpful in ers may not be accomplished in the be effective in treating phantom
deriving a scale of rehabilitation po- predictable sequence or within the ex- pai11. 59 A knowledge of the psycho-
tential for amputees. Kullmann 69 ob- pected period of time. Some individ- logical aspects of amputation and
served that the Barthel index of activ- uals will continue to mourn the loss sensitivity of members of the rehabil-
ities of daily living had a direct of a limb for a long time. Others may itation team, however, are indispens-
correlation with the general condition not deal with the issue immediately, able.
of the amputee and the fitness of the instead returning to it at a much later
prosthesis. Based on these results, the date and exhibiting a delayed grief re-
action. Vivid flashbacks have been re-
Conclusion
Ba1thel index may have prognostic
value for outcome of the rehabilita- ported as a common early reaction to The psychological adaptation to am-
tion of amputees. But as Mendelson amputation. 4 ' 6 1 Reclusiveness, hyper- putation involves many variables and
and associates 40 reported, any psycho- vigilance, and delusions are other stages. With the help of a skilled reha-
logical testing should be deferred un- manifestations of distmbances of bilitation team and a support system,
til the patient is physically and emo- body image.4 With the possible excep- the amputee can adapt successfully to
tionally prepared to withstand the tion of the use of low-dose, low- the challenge of amputation. Most
stress of its administration. potency neuroleptic agents to extin- members of the self-help group noted
Regardless of vocationaJ rehabilita- guish flas hbacks, the opportunity to an improvement in the quality of
tion, resumption and maintenance of ventilate feelings is probably the most their lives after surgery. As one mem-
normal activities, including house- effective therapeutic activity for the ber put it, ''You become a more com-
hold chores, self-care, and social vis- amputee and is a crucial phase that passionate and less critical person to-
its, will avert the vicious cycle of de- should not be aborted. Feelings of wards others." Another, who had
pression and disability. In their study sorrow, anger, and anxiety must be suffered greatly both before and after
of social and psychological facto rs in- expressed before further therapeutic the amputation, said, "When you be-
volved in adjustment to amputation, work can be accomplished. Occasion- come an amputee, you become a bet-
Williamson and associates4 1 obser ved ally, family therapy may be indicated ter person because you have to work
a direct contribution of restriction of to assist in reaching the proper bal- for everything."
act ivity to depression. ance between the legitimate support
amputees need and the independence
Special Approaches they must regain. In addition, psycho-
Acknowledgments
Increasingly, group support is part of logical problems that have been This chapter was written with the as-
the help provided to amputees.3 •43 •52 avoided or disregarded in the past sistance of Richard E. D'Alli, MD, and
One such modality is Schwartz's may surface after the smgical proce- revised fo r this publication with the
situation-transition group, which is dure and be blamed on the proce- able help of Elizabeth Hilton and
clifferent from many self-help groups dure. This might occur in individuals Pippa Newell, senior students at the
for alcoholics, smokers, and overeat- who have had longstanding marital University of Arizona College of
ers in that «members are not required discord, chronic depression, anxiety Medicine.
to espouse a particular moral or be- disorder, drug dependence, alcohol Many individuals assisted in all as-
havioral value system."3 Whether a abuse, and/or antisocial behavior. pects of preparing this chapter. I wish
trained person leads the group or it is These psychiatric challenges can be in particular to acknowledge my debt
conducted entirely by its own mem- addressed therapeutically, without of gratitude to John Bradway, MD,
bers, the group experience is likely to determining the extent to which they who, as a third-year clinical clerk in
be of great value to both the partici- are related to the amputation. If such psychiatry, piqued my interest in this
pants and their families. Amputee a determination becomes desirable, area by preparing a paper on psycho-
self-help groups shy away from self- such as in compl icated legal situa- logical adaptation to amputation,
pity or self-designation in terms of tions, the individual's history a nd which in turn fo rmed the basis of a
disability and emphasize strength and former level of adjustment can be of report wTitten by him, myself, and
participation in a full and healthy great value in clarifying the issue. For several others;30 to James Malone,
Life. 69 most amputees, however, psychiatric MD, for sharing his extensive knowl-
Psychotherapy may be indicated consultation and therapy are not edge and experience; to Joseph Leal,
fo1 individuals who have difficulty required. CP, who put me in touch with the
m<>ving through any of the stages de- With respect to phantom pain, amputee self-help group in Tucson; to
sc.ribed and who are unable to resume biofeedback and relaxation appear to Sharon Stites, leader and organizer of
a 110rmal existence to the extent pos- be useful adjuncts to medical care of the self-help group; to Diane Atkins,
sible for them. It is important to un- the residual limb and measures to occupational therapist and · coordina-

tor for the Houston Center for Am- 10. Dise-Lewis TE: Psychological adapta- 22. White S: Hidden posttraumatic stress
putee Services, who shared a wealth of tion to limb loss, in Atkins DJ, Meier disorder in the mother of a boy with
experience with hundreds of ampu- RH 1II (eds ): Comprehensive Manage- traumatic limb amputation. J Ped
tees at that center; to Sybil Kohl, so- ment of the Upper-Limb Amputee. New Psychol 1991;16:103-115.
cial worker at t he Houston Center for York, NY, Springer-Verlag NY, 1989, 23. Osterman HM, Pinzur MS: Amputa-
pp 165-172. tion: Last resort or new beginning?
Amputee Services, for her profound
observations and reflections on the 11. Parkes CM: Determinants of disable- Geriatr Nurs l 987;8:246-248.
ment after loss of a limb, in Krueger 24. Shukla GD, Sahu SC, Tripathi RP,
lives of amputees; to Jan Pankey and
DW (ed): Emotional Rehabilitation of Gupta DK: A psychiatric study of am-
Sandy Levitt, third-year clinical
Physical Trauma and Disability. New putees. Br J Psychiatry 1982;141:50-53.
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Books, 1984, pp I 05-111.
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12. Williams GM: Restrictions of normal 118- 123.
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The role of public self-consciousness.
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J Rehabil Res Dev 1988;25:vii-x.

The Art of Prosthesis Prescription
John H. Bowker, MD
Introduction
The prescription of a prosthesis no lower limb amputation, energy re- thetic joints. The cost of a prosthesis,
longer involves simply matching a quirements for ambulation increase both initial and ongoing, can also be a
particular level of residual limb with a sharply with each more proximal ana- determining factor in the prescrip-
prosthesis designed for that level. tomic level. These challenges to function. Some insurance companies, for
There are so many choices, in fact, tion are exacerbated by concomitant example, will provide only one pros-
that prescription becomes as much an cardiopulmonary deficits. thesis for the life of the patient. Fiscal
art as a science. This multiplicity of limitations at the local and state levels
options is the result of a revolution in Factors Affecting the may mandate prescribing only a very
prosthetic design, manufacture, and Prescription simple prosthesis for indigent ampu-
fitting made possible by the introduc- A large number of factors affect the tees, similar to those prescribed for
tion of new concepts in socket and amputees in developing countries.
prescription, some of which become
joint design as well as a wider array of Local custom and knowledge can also
apparent only when the parameters of
components and new materials, in- affect both socket and component
the patient's life are examined. First
cluding heat-moldable plastics, light- prescription.
and foremost, the prosthesis should
weight metals, and carbon fiber-rein- meet the needs and desires of the pa- Team Approach
forced composites. tient vocationally, avocationally, and
The prescription of the most suitable
socially as much as possible. Because
prosthesis, taking into account the
prostheses vary considerably in com-
General plexity and resistance to environmen-
above factors, is most effectively ac-
Considerations complished by a team. The team
tal hazards, the limb-fitting team should be both interdisciplinary and
Contraindications should determine both the "gadget interactive, cooperating closely rather
Before discussing the factors involved tolerance" and the ability of the am- than working independently. Al-
in prescribing a prosthesis, a review of putee to provide the level of care though the surgeon cannot be ex-
the reasons for not prescribing one is required for different types of pros- pected to perform the activities of
useful. If the patient's overall health theses. If the amputee lives in a geo- other team members, he or she must
has deteriorated irrevocably to the graphically remote location without be fairly knowledgeable in all areas of
point where the strength or coordina- ready access to a prosthetist for main- prosthetic rehabilitation to effectively
tion required to use a prosthesis is tenance, repair, and replacement of a coordinate the limb-fitting program.
lacking, prescribing one is useless. prosthesis, a simple design that the The primary function of the surgeon,
The patient must have the mental amputee can repair independently aside from providing medical care, is
ability to learn the use, limitations, may be of prime importance. Climate to synthesize tl1e findings and recom-
and care of the prosthesis. At the can also play an important role. In ar- mendations of the team, which ideally
highest levels of amputation in both eas of excessive btunidity, steel parts should consist of the patient and the
the upper and lower limbs, the ability tend to corr.ode and wood tends to patient's family, the surgeon, a physia-
of a prosthesis to restore useful func- rot. In areas of extreme aridity such as trist who specializes in amputee reha-
tion decreases exponentially with pro- desert regions, fine sand particles will bilitation, the prosthetist who will
gressive loss of limb length. Following quickly wear out close-tolerance pros- make the limb, the therapist who will

Follow-up vascular disease has necessitated bilat-

It is obvious that an amputation af- eral transfemoral amputation, it has
fects the amputee for life; however, also affected the heart, brain, and
the need for regular preventive ca.re is other organs. Attempting to walk with
often forgotten. In addition to fre- two full-length articulated prostheses
quent follow- up visits immediately could prove hazardous to these pa-
after the fitting is performed, ampu- tients because of the greatly increased
tees also need to be seen at 6- to 12- cardiopulmonary stress associated
month intervals for the rest of their with the loss of both natural knee
lives. Residual limbs change in vol- joints. Younger bilateral traumatic
ume with muscle atrophy and weight transfemoral amputees are generally
gain or loss, and prostheses require able to walk short distances in full-
maintenance, repair, and periodic re- length prostheses with free knees, but
placement. Failure to monitor these they soon discover that using a light-
factors can result in damage to the re- weight wheelchair is not only less tir-
sidual limb. Prescription modifica- ing but also much faster. Because
tions may also be indicated as in1- walking is so physically demanding,
proved designs become available or for the sake of practicaljty most bi lat-
when the patient's abilities or inter- eral transfemoral amputees use
ests change. wheelchairs for long distances. A non-
ambulatory patient may, however, re-
quest lightweight cosmetic prostheses,
Figure 1 Bilateral transfemoral amputee Lower Limb or a pair of pantyhose can be filled
walking w ith stubbies, which are nonar- Prosthetic with sculpted foam and fitted with
ticulated sockets with rocker bottoms
and pelvic suspension. Prescription shoes to give a pleasing appearance
Indications while the patient is seated in a wheel-
chair.
Reasons for fitting a lower limb pros-
provide the training in prosthesis use, thesis include eliminating the excess Factors Affecting the
a psychologist and/or social worker energy requirements of crutch walk- Prescription
who will help the patient through the ing and improving balance by restor-
adjustment period, and the insurance ing proprioceptive feedback through A bilateral transfemoral amputee who
nurse, especially in worker's compen- the residual Limb- prosthesis interface. is interested in walking and can dem-
sation cases. There is a widely held Equally important, the hands are onstrate sufficient cardiac reserve may
freed for activities other than holding be given a trial with "stubbies." These
misconception that this sort of team
a walker or crutches. In short, the goal are simple, nonarticulated transfemo-
is available only in large medical cen-
is to restore as much functional inde- ral sockets with rocker bottoms and
ters; on the contrary, an effective
pendence to the amputee as possible. pelvic suspension (Figure 1). Young
miniteam can be assembled in most
This varies widely-from returning to trnumatic bilateral transfemoral am-
small- to medium-sized cities. It takes
all previous activities, including active putees will almost always demand a
only an interested surgeon, a local pros-
sports, to the minimum acceptable re- trial of ambulation; they should be
thetist, a therapist, a psychologist/
habilitation goal of assisted transfer encouraged to start with stubbies. Af-
social worker, and an insurance nurse
activities that help the caregiver as ter a variable training period during
to form a team. Once a surgeon ex-
much as the amputee. Another con- which the amputee can assess the en-
presses an interest in this type of ergy required to walk while the team
siderable benefit is the restoration of
work, other local surgeons are very evaluates the amputee's motivation
the amputee's body image that a pros-
likely to refer patients. By meeting thesis may provide. level, balance, and donning skills, the
once or twice a month at the sur- amputee may be able to use articu-
geon's office or other designated loca- Contraindications lated Limbs. In most cases, it is pru-
tion, team members can work more Cogent reasons also exist for not fit- dent to add feet and longer pylons to
effectively than they can individually ting lower limb prostheses, especially the stubbies before introducing pros-
with no interchange of ideas. This ap- in dysvascular patients with bilateral thetic knees.
proach also helps to improve pre- transfemoral amputations. Fitting A unilateral dysvascular transfem-
scription practices and tends to posi- such debilitated amputees with artic- oral amputee may not be able to mus-
tion the participants in leadership ulated prostheses is rarely successful ter the cardiopulmonary reserve to
roles in this field. in the long term. By the tin1e severe manage even household ambu lation

Chapter 58: The Art of Prosthesis Prescription 741
and will often request a wheelchair.

Amputees with hip disarticulations
or transpelvic amputations, typically
yo unger trauma or twnor patients,
often use a prosthesis for long-term
community ambulation. Some pa-
tients, however, may find that the
slower speed of prosthetic walking is
the overriding factor in rejecting
prosthesis use on most occasions. Ma-
jor discomfort while sitting in the
prosthesis may also become a factor
in rejecting the prosthesis. If external
aids are required for prosthesis use,
the prosthesis provides little, if any,
functional advantage over crutch
walking without a prosthesis.
Patients should not be rejected for
fitting of unilateral or even bilateral
lower limb prostheses solely on the
basis of age. Many elderly patients can
be successfully fitted at the transtibial,
Syme ankle disarticulation, or knee
disarticulation level provided that
they are physiologically sound and are Figure 2 Ninety-year-old man w ith a Figure 3 Seventy-three-year-old man with
mentally capable of comprehending right Syme ankle disarticulation and a a long right transtibial amputation. As a
the subtleties of sock adjustment ne- left transtibial amputation. Like many result of a cerebrovascular accident, he
cessitated by changes in residual limb elderly bilateral amputees with two in- has a left hemiparesis with moderate
tact knee joints, he became a successful f lexor patterning while walking. The left
volume (Figure 2) . In borderline
limited community walker. shoe lift and the right alignment device
cases, transtibial amputees can be fit- were removed upon completion of the
ted with inexpensive preparatory prosthesis.
prostheses to realistically assess their should be able to walk without assis-
potential for ambulation and to facil- tance in familiar surroundings,
itate transfers. though community ambulation may realistic expectations of functional
Many younger lower limb ampu- be safer with a companion. The fitting outcome. In addition, the societal and
tees, especially those with amputa- of blind unilateral transfemoraJ am- individual costs of inappropriate or
tions at the transtibial level, will wish putees should be approached with unnecessaTy fittings can be enor-
to resume previous sports activities. great caution. A free knee is usually mous.
Should the amputee be interested in contraindicated because of the loss of To provide some guidelines, Gailey
participating in any activities based proprioceptive knee function. Pa- and associates 1 have devised the Am-
on running, a variety of dynamic- tients with hemiparesis following a putee Mobility Predictor (At\1P) to
response carbon fiber prostheses are cerebrovascuJar accident can often measure an amputee's ambulatory
available. Some amputees will benefit walk with transtibial prostl1eses pro- potential with and without the use of
from prostheses designed for specific
vided that they have adequate menta- a prosthesis. Tbe evaluation consists
sports, including those made specifi-
tion and balance and no disruptive of 21 simple task-oriented measure-
cally for skiing, swimming, or sprint-
spasticity or severe extensor or flexor ments that can be completed in less
ing. Because of these complexities, ef-
patterning (Figure 3). than 15 minutes. The resulting score
fective management is best achieved
can be reliably linked to the Medicare
by a team as described above. The Amputee Mobility
Blindness and hemiplegia are addi- Functional Classification System for
tional factors that may enter into the
Predictor the purpose of prosthetic prescrip-
fitting of lower limb amputees, partic- Assessing the readiness, both physical tion. Neither the AMP instrument
ularly diabetics. Once properly and psychological, of an amputee for nor Medicare guidelines apply to bi-
trained, blind amputees with unilat- prosthetic fitting and training can be lateral amputees, however, whose
eral or bilateral Syme ankle disarticu- daunting. Patients, families, and even unique situations require case-by-case
lations or transtibial amputations professional caregivers may have un- review.

a prosthesis than are foot function low in cost, it is important to provide

and cosmesis by a lower limb prosthe- a detailed explanation of what is real-
sis. istically available. This discussion
should include the basic differences
Factors Affecting the between body-powered and myoelec-
Prescription tric limbs, as well as the limits of
Successful fitting of the upper limb prosthesis function versus function of
amputee depends largely on the pa- an intact upper limb. The complexity
tient's motivation, which is usually of various prostheses must be ex-
highest immediately after amputa- plained, and the tolerance of the indi-
tion. This is especially true in bilateral vidual amputee for each should be
Figure 4 To prevent the development of
amputees, where the person is totally ascertained. The amputee shou ld un-
complete one-handedness, an IPOP
should be fitted w henever possible, as in dependent on others for most activi- derstand that despite the obvious cos-
this left transradial amputee. ties of daily living, including dressing, metic advantages of myoelectric pros-
eating, and toileting. It is useful, theses, they are very costly, they are
therefore, to fit bilateral upper limb heavier than most body-powered
Effect of Delayed prostheses, and they require more
amputees with immediate postopera-
Prescription tive prostheses (IPOPs) whenever maintenance. The patient should
Delaying prosthetic fitting and meet as often as necessary with team
possible to provide prehensile tools
training of the unilateral dysvascular members, collectively or individually,
that will restore significant indepen-
amputee to prevent stress to a com- to obtain information about the pros-
dence.
promised remaining foot is not rec- thesis and its use. The entire team
The motivation of the unilateral
ommended, as this approach will should then meet again with the pa-
amputee for prosthetic fitting is also
result in months of avoidable decon- tient before actually ordering the
highest immediately after amputa-
ditioning and tends to accustom the prosthesis. With high bilateral ampu-
tion. The surgeon should use this
patient to wheelchair use. If the sec- tation, consideration should be given
window of opportunity to prevent the
ond foot is later amputated, simulta- to modifying the amputee's environ-
development of complete one-hand-
neous fitting. as a debilitated bilateral ment as much as possible for more ef-
edness by fitting an !POP so that the
amputee is much less likely to pro- fective function.
amputee will awaken from surgery
duce useful walking than if the pa- Blindness presents particularly dif-
with a device in place to assist the in- ficult problems for the upper limb
tient had been fitted as soon as possi- tact hand (Figure 4). Two basic fac-
ble after the first amputation. The amputee because the dexterous con-
tors regarding these prosthetic fittings trol of any terminal device is highly
dysvascular amputee who loses one should be noted. First, successful fit-
foot should therefore be made ambu- dependent on visual feedback. Be-
ting of the unilateral upper limb am- cause of this, a blind bilateral transra-
latory with a prosthesis as rapidly as
putee is unlikely after the amputee dial amputee will have great difficulty
possible. If the second foot is lost, the
has become fully functional with one grasping objects independently with
patient will be an accomplished uni- hand, which usually occurs within the
lateral prosthesis user and will be an active terminal device. ln this situ-
first 3 months. Second, prosthetic fit- ation, therefore, consideration should
more likely to learn to walk with two
ting is at the discretion of the unilat- be given to a Kmkenberg procedure
prostheses.
eral amputee, although most upper on one or both sides. A blind unilat-
limb amputees who are fitted early eral upper limb amputee may find a
Upper Limb find that a prosthesis enhances their passive prosthesis useful for holding a
Prosthetic function. Early intervention, there- coat or carrying certain objects.
fore, can best be provided by a spe- As with lower limb amputees,
Prescription cialized upper limb prosthetic team, many upper limb amputees want to
The impact of hand loss is very differ- which should include a behaviorist to return to the sports and recreational
ent from the impact of foot loss. assist the amputee in working through activities in which they previously
Awareness and use of the hands for the grieving process. participated. These individuals have
grasping occur much earlier in in- The fust step in prescription of a the option of using myoelectrically
fancy than the use of the lower limbs definitive upper limb prosthesis is de- controlled hands or body-powered
for walking. The hand has greater termining the amputee's expectations. terminal devices featuring passive or
physical and psychological signifi- Because every amputee wants to reactive prehension. A variety of termi-
cance than does the foot. The func- ceive a prosthesis with a hand that nal devices designed for specific
tion and cosmesis of the upper limb looks real, functions like the limb that sports and recreational activities are
are much less completely replaced by was lost, is easily maintained, and is available and should be carefully

Chapter 58: Th e Art of Prosthesis Prescription 7 43
matched to the patient's needs and myoelectric device at work and switch tee, become available. As significant
desires. Individuals who engage fre- to a body-powered prosthesis for advances in prosthetic research and
quently in a variety of activities may working in the garden after hours. development occur, a progressive
require several different interchange- Conversely, a manual laborer, such as team will keep thefr amputee clients
able terminal devices appropriate for a welder, may use a body-powered appropriately informed of potentially
those activities. prosthesis or a myoelectric gripper at useful changes in their prosthesis pre-
work and switch to a more cosmetic scriptions. Recommending a change
Payment Considerations myoelectric hand prosthesis for social in a prescription, however, should be
Because most upper limb amputa- functions. Even par t-time use of an made only after tl1orough discussion
tions are traumatic and many are job upper limb prosthesis for specific vo-
of the amputee's individual needs and
related, third-party payment for pros- cational, avocational, or purely social
desires by the entire prosthetic team.
theses plays an important role in pre- purposes is a sign of acceptance of the
As director of tl1e team, the surgeon
scription. Some insurers may require prosthesis, making it worthy of initial
bears a particular responsibility, espe-
all upper limb amputees to be fitted provision and replacement as neces-
cially as prosthetic technology be-
with a lower cost body-powered pros- sary. Some patients who have lost a
thesis to demonstrate "adequate" mo- lin1b from trauma or tumor at a high comes increasingly complex and ex-
tivation before being allowing a level may decide to forgo any prosthe- pensive. Change for its own sake often
higher cost myoelectric limb. This ap- sis or to use a very light passive device proves counterproductive, especially
proach does not take into account if it is cosmetically acceptable. in older patients who are satisfied
amputees whose amputation level with their original prescription. For
makes tl1e use of a body-powered example, although a more complex
prosthesis impractical. Nor does it Summary transtibial prosthesis "Yith an elasto-
suit the needs of those for whom cos- The prescription of a prosthesis re- meric liner and distal lock may pro-
mesis is an overriding concern, in- quires matching the needs and prefer- vide improved suspension, many eld-
cluding individuals who meet the ences of an amputee with the many erly amputees may find it harder to
public in their daily work. Many of prosthetic options available witl1in don than a simpler patellar tendon-
these amputees will refuse to consider the parameters of available funding. bearing/supracondylar prosthesis. Pa-
any terminal device that does not rea- Contraindications to prosthetic fit- tients should therefore be made aware
sonably resemble a hand. This atti- ting in terms of diminished physical of the possible impact of any change
tude can be attributed to body image or mental capacity must also be rec- and should never be coerced to dis-
or, in many cultures, to societal accep- ognized. Many amputees may require card a previously successful prescrip-
tance. Therefore, tl1e realistic prefer- two different prostheses to reach tl1eir tion, no matter how outdated it may
ences of the individual amputee with full functional potential-for exam- appear.
regard to function and cosmesis must ple, one designed for outdoor use and
be supported strongly by the rehabili- one for limited indoor use. Prosthetic
tation team dUl'ing negotiations with prescription should be accomplished Acknowledgment
the third-party payer. by a well-integrated interdisciplinary The author wishes to express thanks
Another question often raised, es- team, with the patient and family as to Ms. Patsy Bain for her expert prep-
pecially by third-pa1·ty payers, is the active participants. aration of th is manuscript.
definition of what constitutes success- After the initial intensive effort in-
ful use of an upper limb prosthesis volved in prescription, fitting, and
and what justifies its replacement tramrng has been completed, Reference
over time. Is successful use defined by follow-up should continue through- I. Gailey RS, Roach KE, Applegate EB, et
the number of hours of wear each out the life of the amputee, with at al: The Amputee Mobility Predictor:
day? Many amputees wear the pros- least yearly evaluations by the appro- An instrument to assess determinants
thesis during working hours and re- priate lower or upper limb team. of the lower-limb amputee's ability to
move it at home for comfort although Prostheses wear out and sometimes ambulate. Arch Phys Med Rehabil
it has been extremely useful at the break, and new designs, which might 2002;83:613-627.
workplace. Other amputees wear a provi.de advantages to a given ampu-

of a cha ir to work the fingers into A single padded hook or wooden

place. 6 A mitten is simpler to manage knob on the wall can aid dressing.
than a glove. A wristwatch with an ex- One section of the trousers, skirt, or
pandable bracelet-type ba nd goes on shirt is secured to the hook while the
more easily than one with a buckled person maneuvers into the garment. 18
strap, although the latter can be man- An alternative for donning both un-
aged.14 To put on the bracelet watch, derpants and outer pants is to first
the patient lays the watch on a table place them on the floor; then, while
and cups the fingers inside the band, seated, to insert the feet into the pants
then uses the table edge to slide the legs; and finally to raise the legs.
watch onto the wrist. 6 Adults will find Shaking the torso and legs causes the
that using a wallet with separate com- pants to slide down tbe raised legs, to-
partments for small and large denom- ward the waist. When the pants are at
ination bills reduces the likelihood of the buttocks, the individual uses fric-
making errors when shopping.4 tion between the floor and pants to
work the garment into place. A fabric
Bilateral Amputation loop sewn to the waistband allows an-
other means of independently don-
Figure 1 Ma n wit h trau matic bilateral Patients who have undergone bilateral
ning trousers. 19 To accomplish this,
t ransradial a mputat ions dons cotton amputations should be guided to
stockinette tee shirt by using his forea rm the person with a transradial amputa-
make maximum use of the rem·a ining
t o stretch the fabric near the hem to cre- tion slips the forearm through the
portions of their limbs to perform
ate a "pocket, " which ena bles him to loop to stabilize the waistband. Alter-
slide t he shirt over his torso. daily activities, such as dressing. The
natively, the individual with a transra-
antecubital fossae and, to a lesser ex-
dial or higher amputation can hold a
tent, the axillae can be used to hold
knot. 4 •6 •13 Putting on pants is easiest rod with a hook at one end in the
items. Objects may also be stabilized
if they are placed on a bed near a wall. teeth or the antecubital fossa, then
in the teeth and between the thighs.
The patient sits on the bed, inserts slip the hook through the loop.
Some adults are limber enough to be
one leg into a pants leg, and then A child with a phocomelic hand
able to grasp with the feet. A jeweler can manage underpants to which a
leans against the wall to hold that side
can resize wedding and other rings so tape has been sewn from the middle
while putting the other leg into the
they fit on the toes or can create a
garment. 7 of the front waistband to the middle
brooch from rings. 15 of the back waistband; the tape
Managing a brassiere, especially
The child with congenital bilateral drapes over the front and continues
one with a front closure, requires least
effort if it is laid out on a bed. The limb deficiencies should be encour- to the back of the garment.20 With a
woman lies supine over the garment, aged to manipulate with the feet. 16• 17 reacher, a stick with a hook at one
sups the amputated limb through one The feet provide tactile sensation and end, the amputee can lower and raise
strap, then inserts the contralateral considerable prehensile function, so the pants.3
arm through the other strap. Velcro manipulation with the feet can red uce
tape is easier to secure than are hooks reliance on adaptive equipment and Grooming and Hygiene
and eyes.4 Blouses and shirts are help from others. The family and pa- Unilateral Amputation
donned by first inserting the residual tient may require psychological sup- Although patients with unilateral am-
limb into one sleeve and then the op- port to overcome an aversion to see- putation should have little difficulty
posite limb into the other. A buttoned ing or using the feet to accomplish with grooming activities, some prefer
cuff should be fastened before don- ordinary tasks. the convenience of scrub and denture
ning the shfrt; securing the cuff but- Undergarments that can be put on brushes, nail fil es, and clippers stabi-
ton with elastic thread may be needed and taken off by the person are espe- lized with suction cups.9 •16 One could
to allow room for th e hand to slide cially important to fostering indepen- also stabilize a nail file or emery
easily through the cuff. A necktie can dence in both children and adults board between the thighs. Filling the
be knotted one-handed,2 particularly (Figure 1). Two tape loops can be cheeks with air to make the skin taut
if the narrow end of the tie is held to sewn to the waistband of underpants. speeds shaving. By bathing at night,
the shirt with a tie clasp. Pretied, The amputee can then hang the un- the person is ensured of having the
clip-on neckties are another option. derpants on two wall hooks installed skin dry before dressing. Either a
To don a glove, the individual can at a height suitable for stepping into wall-hung liquid soap dispenser or a
press it against the ipsilateral hip. the pants. Once the underpants are soap bag made from a waffle-weave
Once the hand is partway into the on the torso, the individual can rise dishclotl, 4 helps tl1e cleaning process.
glove, the amputee can use the back on the forefeet to release the loops.3 Ridged caps on toiletries are easier to

Chapter 59: Rehabilitation Without Prostheses 747
manage than are smooth-sided lids.

Similarly, flip-top pill containers are
far preferable to childproof bottle
tops. Liquid antiseptic in squeeze bot-
tle or spray form takes less effort to
apply than coping with an individu-
ally wrapped adhesive bandage.
Bilateral Amputation
Individuals with bilateral transradial
amputations can use a sponge mitt
over one forearm for soaping and
scrubbing. Alternatively, a terry cloth
or waffle-weave doth mitt can hold a
bar of soap. 2 1 For cleansing while in
the shower, the patient can loop one
end of a strip of toweling over the
showerhead by maneuvering with Figure 2 Fork secured to forearm with
both residual limbs. The other end of elastic bandage.
the strip adheres to the tub floor by
means of suction cups or the bather's
seat equipped with a water spigot and
foot. Most individuals can operate
warm airflow is suitable for the home.
faucets with the feet, particularly if
A vaginal tampon applicator for
the faucet has a flange rather than a Figure 3 Persons with bilateral upper
women with bilateral amputation25 as
knob handle. 9 ' 22 Similarly, flanged limb deficiencies or bilateral shoulder dis-
well as other hygienic aids can be articulations use the feet for many activi-
faucet handles at the washbasin are
constructed easily. 26•27 ties, such as opening a can (A) and pour-
convenient. A terry cloth bathrobe ing from a can into a glass (B).
The patient with phocomelia can
simplifies drying oneself. 21
use a reacher stick with a padded
Urination and defecation are made
hook or wire coi l at one end to secure
easier with the appropriate clothing Bilateral Amputation
that can be easily loosened or re- toilet paper. 28 Various grooming aids,
such as a comb, hairbrush, and tooth- A utensil holder designed for individ-
moved. For men and boys, the trouser uals with quadriplegia can be worn
zipper may be left partially open, cov- brush, may be attached to a similar
stick. on the forearm of an amputee with at
ered by the hem of an overshirt. The least one transradial-length residual
individual can urinate independently, An electric floor model shoe buffer
helps amputees take care of their limb. The holder accommodates a
particularly if he does not wear un-
shoes. spoon, fork, and other objects. A fork
dershorts. Defecation is aided if the
or spoon can be strapped or ban-
client wears slacks with suspenders,
Dining daged to the forearm (Figure 2). If the
rather than a belt. He can then pull
Unilateral Amputation residual limbs are long enough, the
the trousers down by grasping tl1e
A commercial fork clip secures the person does not need any device to
pants leg with the toes. Some girls
and women find that underpants utensil to the plate so that the con- hold eating utensils and can merely
modified with a split crotch facilitate tralateral hand can cut meat. A stabilize the fork or spoon between
toilet activity.23 Undergarments de- snap-on plate guard is useful for be- the ends of tl1e residual limbs. 30
signed for incontinence are another ginners because it serves as a stable Persons with bilateral upper limb
option to augment security. area they can push food against. The deficiencies or bilateral shoulder dis-
Some patients regulate their diet so rocker knife facilitates one-handed articulations must use the feet for
they can defecate at home in the cutting; one model has prongs so that many activities such as opening a can
morning or at night. Perinea! cleans- the user can spear food morsels. 24 •29 and pouring from a can into a glass
ing can be accomplished by foot and Alternatively, patients can omit from (Figure 3). Often, the toes become as
trunk motion. Toilet paper is held in their diet steak and other large pieces dexterous as fingers, and indepen-
the toes or placed over the heel; the of meat they would have to cut. Tech- dence in many eating activities can be
person t hen rocks over the foot. 9 Oth- niques fo r buttering bread and open- achieved.
ers drape paper over the rim of the ing a milk carton are easy to learn. 13 Striking a match (Figure 4) can
toilet and straddJe the bowl to wipe Chopsticks are another mode of one- also be accomplished by the toes. Toe
themselves.24 A bidet or special toilet handed dining. dexterity such as this is achieved only

Figure 4 Striking a match can be accom-

plished by someone born without arms.
Toe dexterity is possible only in a person
with congenital absence of both arms or
a person w ho has lost both arms at a
high level at a very young age.
by those born without arms or those

who have lost their arms at a high
proximal level at a very young age.
Reading and
Communication Figure 5 Child holding chalk in her t oes to draw on a slate.
Unilateral Amputation
The p erson with amputation of the page turners are an expensive alter- than fabric ties can be slipped onto
right hand will find that writing with native. To write, the patient can the waist with one hand. A board with
the left hand is easier on a table rather secure the paper in a clipboard or use stainless steel holding pins secures
than on a right-armed writing desk. the transradial resid ual limb or the potatoes and other firm vegetables so
The individual should slant the paper chin to nudge the paper into position. that one can peel with the sound
in the opposite direction from that Some agile individuals can manage hand. One-handed jar openers, beat-
used by right-handers to avoid twist- a commercial one-handed writing ers, mashers, and choppers, plus elec-
ing the left arm into a cramped board that clamps the paper and has tric can openers are sold in most
posture. Someone with unilateral am- rubber feet to prevent the board from housewares stores. 13 Lightweight
putation can use one-handed touch- slipping on tl1e table. The pen can be bowls and pans are easy to lift single-
typing methods devised for those held in a forearm cuff, tl1e teeth, or, if handed. A mixing bowl can be stabi-
13
with cerebral palsy.31 •32 Computer one is limber, the toes. The client with lized by placing it on a rubber mat
keyboards designed for unimanual bilateral transradial or elbow disar- or setting it into a bowl holder or into
use are readily available; they substi- ticulation amputations can use both a drawer that is closed snugly against
tute a different letter configuration limbs to stabilize a pencil, pen, or the bowl. Eggs can be broken one-
fo r the usual QWERTY key arrange- crayon for writing and drawing or handed,6 and separators can be used
ment.33 For telephone dialing, one use the toes 30 (Figure 5). The begin- to separate whites from yolks.
can place the receiver on the desk. A ner will find that a felt-tipped mark- Some chores such as folding laun-
commercial speaker phone or heading pen makes writing easier than a dry are aided by using the teeth as a
band eliminates the need to stabilize ballpoint pen. Touch-tone phones holder. Child care tasks can be man-
the receiver against the shoulder with with oversized buttons are widely aged efficiently by using one hand
the head while writing a message. available and can be dialed easily us- while securing the infant against one's
Many consumer phones include a i11g the tip of the residual limb or the torso with the amputated limb or re-
speakerphone option that eliminates olecranon . lying on the crib or other flat surface
entirely the need to use the handset. for stability.34
Homemaking and Other Sewing begins with threading the
Bilateral Amputation Vocations needle, which can be secured by slip-
Many special equipment manufactur- Unilateral Amputation ping it into one's shirtsleeve, skirt, or
ers offer book holders. The reader A full range of cooking is possible for trouser leg, or one can use an auto-
turns pages with the bare residual the single-handed chef. 4 An apron matic needle threader. Left-handed
limb or a mouth stick; commercial with a semirigid plastic clip rather scissors are sold in most needlecraft

shops.35 Embroidery and extensive

sewing are less arduous if one uses an
embroidery hoop on a floor stand,
which frees the hand to wield the nee-
dle. A knitting holder damped to a ta-
ble facilitates one-handed knjtting.
The residual limb makes an effec-
tive stabilizer in many carpentry and
office tasks.21 Nails can be set with
one hand by holding the nail against
the hammerhead and swiftly slam-
ming it against the wood to be
nailed. 24 Farm equipment and work-
site modifications enable the amputee
with unilateral amputation to accom-
plish most tasks efficiently.36 Because Figure 6 Sewing is accomplished by a bi-
farming and many other vocational lateral upper limb amputee w ith toe dex-
and avocational pursuits involve op- terity. The needle is threaded by inserting
the needle into a pincushion or into the Figure 7 Sculpting tool secured to the
erating a vehicle, using a spinner
fabric to stabilize the needle or by using forearm with an elastic webbing band.
knob on the steering wheel should a metal needle threader.
prove helpful. 24
The adult with an amputation of
the right hand can greet a visitor by Simple devices aid the golfer, gar- Bilateral Amputation
extending the intact left hand with dener, carpenter, and fishing enthusi- Swimming, soccer, and kickball are
the forearm fully pronated. 37 ast.39 For example, a one-handed fish- obvious recreational choices for tl1e
ing vest holds the rod so that tl1e user child or adult with bilateral arm am-
Bilateral Amputation can cast and retrieve. An alternative is putations at any level. A leather mitt
A reacher stick can help the amputee a broad waist belt fitted with a pocket riveted to the side of each aluminum
engage in light household tasks. to hold the pole. The camera tripod ski pole accommodates the skier with
Those with bilateral transradfal am- can be modified to support a bow for traosradial amputations. Bilateral lon-
putations may make considerable use the archer who has unilateral amputa- gitudinal deficiencies do not preclude
of the antecubital fossae for holding tion. Cameras designed for one- playing tennis.45 One can shoot clay
packages, which can then be opened handed operation feature a pistol pigeons with a modified shotgun se-
with the teeth. The elbow or shoulder grip, a trigger to snap the shutter, and cured to the upper arm by an alumi-
can flick a light switch on and off. an automatic focus mechanism. The num ring.46 For those who enjoy cre-
With practice, even such fine motor billiards player can use a mobile ating sculptures, sculpting tools can be
tasks as threading a needle can be ac-
bridge to support the cue stick; strapped to the forearm (Figure 7).
complished with just the residual
mounted on two wheels, the bridge
lµnbs if they have sufficient length to Music
has a hole for the stick. Wrist disartic-
oppose one another. T he dexterity re-
ula tion did not preclude a career as a Sometimes simple modifications or
quired to accomplfah such tasks with
major league baseball pitcher for Jim variations from customary perfor-
the toes, however, develops only in
Abbott, who played for the Angels, mance practice can allow patients to
persons with bilateral limb loss that
was present at birth or that occurred Yankees, White Sox, and Brewers from play musical instruments. 47 Singing is
at a very young age because they can 1989 to 1999.40 Bicycle riding is easier a form of musical expression that
achieve sufficient hip range of motion for a cyclist with a transradial ampu- needs no special equipment or tech-
to bring the feet together at chest and tation if one end of a webbing strap is nique.
face level and higher (Figure 6). looped around the residual limb and
the other end over the handlebar. 4 1 Unilateral Amputation
Sports and Recreation Children with transradial amputa- The musician with transradial ampu-
Unilateral Amputation tions can jump rope by securing the tation can support a trumpet on the
One-handed card shuffling requires rope to the forearm of the resid ual amputation limb, with an adapted
some dexterity.38 Otherwise, the am- limb with an animal harness made of neck strap, or on a custom-made
putee can use a bowl or hat to hold webbing. 42 Golf can be played if sim- stand. Although valves are designed
the cards; commercial playing-card ple modifications are made to the for the right hand, they can be de-
shufflers are inexpensive alternatives. dubs. 43,44 pressed with the left.

The French horn is particularly keyboard instruments are another op- per li mb amputation who does not
suitable for those with amputation. tion for unimanual playing. wear a prosthesis can accomplish
Conventional performance assumes daily and vocational activities rather
valve control with the left hand; thus Bilateral Amputation easily, often without using assistive
the player with right transradial am- The musician with bilateral transra- devices. Basic skills are, however,
p utation places the bare amputation dial amputation qm sit and support much more daunting for the person
Limb in the bell. A cupped cardboard the bell of a trumpet on the leg; either with bilateral upper limb amputa-
or plastic fixture mounted in the bell or both amputation lin1bs push the tions. In contrast, the person with
facilitates pitch regulation. A person valves, depending on the desired note. unilateral or bilateral amputation of
with left amputation can play in re- The bugle can be held by a neck strap the lower limbs who does not wear
verse, although balancing the horn or floor stand; because it has no prostheses is likely to have much
will be somewhat cwnbersome. If the valves, pitch is determined solely by more difficulty with certain tasks, es-
player develops a serious interest, an the musician's mouth. Assembling the pecially ambulation, than those who
instrument with tubing coiled in re- instrument is accomplished by asking use prostheses.
verse can be manufactured . Instru- a friend to assist, or the player can use
the broad, resilient surfaces of the Clothing Selection and
mentalists with left amputation can
manage the larger brass instruments transradially amputated limbs to sta- Dressing
such as the tuba by supporting the in- bilize the brass segments. Unilateral Amputation
strument on the lap or on a commer- Borrowing from the one-man- The person who intends to ambulate
cial chair-stand and working the band tradition, people with bilateral with crutches should select a low-
valves with the right hand. amputation can wear a rigid neck heeled shoe for the sound foot. Laces
Numerous ways of striking drums, support for the harmonica to facili- or a strap that fastens high on the
xylophones, and other percussion in- tate playing by moving the mouth dorsum of the foot will prevent the
struments make them accessible to along the instrument rather than the shoe from slipping off the foot when
virtually aU persons with amputation. usual method of moving the instru- the leg swings forward.
The musician with transradial ampu- ment along the mouth. One or a pair
tation holds the mallet or stick in the
of leather cuffs worn by a percussion- Bathing
intact hand and has the other mallet
ist with bilateral transradial amputa- Unilateral and Bilateral
secured to a snugly fitting leather cuff
tions enables playing the triangle, Amputation
chimes, and gong suspended from a A bath chair with a plastic seat and
on the forearm. A do Ltble-headed
stand. Shaken instruments such as rubber- tipped legs contributes to
drumstick enables the bass drummer
maracas can be secured with the safety in the shower or bath. Some
to play while marching. Tambourines
cuffs, particularly if the handle is cov- models have an extension that fits
and bells are ideal for the person who
ered with friction tape to increase sta- over the edge of the tub to aid trans-
can hold the instrument in the sound
bility in the cuff. A sn ugly fitting san- fer. Strategically placed wall-mounted
hand.
dal modified to hold a plastic pick bars increase safety during transfers.
The player with transradial ampu-
enables one to play stringed instru- Waterproof shower prostheses are sel-
tation can strum a guitar with a pick
ments with the foot. Some guitarists dom ordered. Narang and associates49
secured in a forearm cuff. Some musi-
are able to simply strum with the pick found that nearly all the adults they
cians with transcarpal amputation
held in the toes.48 surveyed with lower limb amputa-
who retain wrist motion hold the pick
The piano and other keyboard in- tions sat on the shower floor to bathe.
in the wrist. Those with left amputa-
struments are accessible to children The few who stood or used a stool,
tion reverse the strings and bridge
with phocomelia who play by sitting
and, for the steel-stringed guitar, the predominantly those with bilateral
on a low stool so that they can extend
pick guard also. Commercial left- amputations, relied on grab bars to
their smaU limbs to reach the keys
handed guitars are another option. assist balance.
with bare fmgers.
The conventional guitar strap helps
support the instrument, as does the Ambulation
footrest ordinarily used on the right Skills for Patients Unilateral Amputation
side. The banjo and ukulele can be With Lower Limb The person who does not wear a
played in a similar manner. prosthesis may be able to manage
One-handed performance on the
Amputations with a pair of axillary or forearm
piano and other keyboard instru- The functional problems that attend crutches. Some individuals in good
ments can feature music chosen from lower limb amputation differ from physical condition, with particular re-
a large literature ra11ging from ele- those associated with loss of an upper gard to the upper limbs, heart, and
mentary to virtuoso pieces. Electronic limb. The person with a unilateral up- lungs, walk smoothly and efficiently

for Long distances with crutches. Forearm crutches are more com- HoppiJ1g is another means that
Young adults with hip disarticulation pact than axillary crutches. Among unilateral amputees who are in good
or transpelvic amputations some- subjects with transfemoral amputa- physical condition use to move over
times opt for crutches because they tion, the use of forearm crutches re- relatively short distances. Even those
can ambulate faster than with a pros- sulted in a freely selected speed that who use a prosthesis may hop to get
thesis. For those who rely on a wheel- was 15% to 40% slower than that to the swimming pool from tl1e locker
chair, crutch walking may facilitate chosen by able-bodied persons; en- room. The individual should en-
maneuvering in small or crowded ergy cost per unit distance ranged deavor to land lightly with a springy
rooms. Occasional use of crutches from 48% to 70% greater than that step on each hop to prevent spraining
counteracts the negative conse- for able-bodied persons. When the or fracturing the foot. The trunk
quences of prolonged sitting, such as same subjects were tested with their should incline slightly forward, and
the formation of contractures and prostheses, walking speed was 12% to the foot should be lifted from the
pressure sores. 33% slower than able-bodied control ground as short a distance as possible.
Crutches must be the proper subjects, at a metabolic cost 30% to To traverse very brief distances, the
length. The handpiece should be set 40% greater than normal. 52- 54 A person may prefer to pivot on the
at a point that permits the user's el- walker is a more stable alternative to a foot, alternating between the heel and
bow to be slightly flexed. A resilient pair of forearm crutches. forefoot. The maneuver is less stress-
rubber or plastic foam handpiece Those whose balance is poor or ful than hopping. 50
cover reduces the risk of the hand whose arms are not strong require the To operate an automobile, t he
slipping, especially if it is damp with added support of axillary crutches, driver with a right amputation should
perspiration. Alternatively, some indi- rather than forearm crutches. Subjects have a car equipped with a hand
viduals prefer to wear gloves to in- with transfemoral amputations con- parkin.g brake on the console between
crease control of the crutches. The ax- sumed approximately the same the driver's and passenger's seats. The
illary piece, that is, the top bar of the amount of energy whether walking motorist depresses the accelerator and
axillary crutch, should be two finger with axillary crutches or with a pros- brake pedal with the intact left foot.
widths from the axiHa to avoid com- thesis, although the pulse rate aver- Another option is to have tl1e car
pression of the superficially located aged 39% higher with the crutch- modified so that the accelerator is lo-
radial nerve. A resilient cover ines.52•55 Using a single axillary crutch cated to the left of the brake pedal.
creases the friction of the axillary often promotes a significant shift of
piece, which should be kept next to body weight toward the crutch and Bilateral Amputation
the chest. For both styles of crutch, exposes the walker to the risk of im- Most people with bilateral lower limb
the tip should be a large suction one pinging axillary vessels and nerves. amputation require a wheelchair for
to increase traction on the floor. Ascending stairs with one leg and a long-distance mobility, often as the
For good posture, the crutches pair of crutches is somewhat less in- primary mode of transport. The chair
must be kept parallel to the trunk to timidating than descending, particu- should have its rear wheels set back to
minimize pressure on the chest. The larly if the aids are forearm crutches. compensate for the posterior shift of
body should progress forward in a One can increase safety by keeping the user's center of gravity. While
continuous manner. The walker tl1e crutch tips close to the edge of the swing-out footrests are appropriate
moves the residual limb in the oppo- step with the crutches inclined toward fo r those who wear cosmetic or func-
site direction from the contralateral t he top of tl1e stairs. Young adults tional prostheses, people who do not
leg, rather than maintaining the resid- consumed 49% more energy ascend- wear any prostheses can transfer to
ual limb flexed, to create a rhythmic, ing stairs with axillary crutches than and from the chair more easily if
swinging gait. so did able-bodied control subjects.52 there are no footrests (Figure 8). A re-
Walking with crutches without a Those with transtibial amputations clining wheelchair relieves the dis-
prosthesis is physiologically stressful performed less efficiently with comfort of prolonged sitting.58 An
and associated with markedly ele- crutches than they did with prosthe- overhead trapeze bar facilitates mov-
vated heart rates for those with am- ses. Crutch use was associated with ing from tl1e bed to the wheelchair,
putations, whether because of vascu- greater energy cost and slower speed; particularly when elbow extensors are
lar disease or trauma. Heart rates are subjects had to lead with the intact leg not strong enough to lift the body
elevated to an average of 130 beats/ and then raise the crutches. With the weight with the usual push-up ma-
minute among crutch users, compara- prosthesis, they could climb step over neuver. For other transfers, a wooden
ble to the stress that jogging imposes step.56 Young adults with transtibial or plastic sliding board may be used.
on able-bodied persons.51 Conse- amputation were 48% less efficient It bridges the gap between the wheel-
quently, for most individuals, with crutches but only 29% Jess effi- chair and the transfer goal, such as
crutches should be considered only cient with prostheses than were able- the bed. With the board in place, the
for traveling short distances. 52 bodied adults. 57 individual can shift weight from one

The automobile should be bilateral leg amputation include

equipped with hand controls for safe horseback riding, motorcycling, skate-
operation. The controls, however, board stunts, and weight lifting. For
should augment rather than replace example, the saddle on a horse or the
conventional foot controls so that motorcycle seat can be fitted with a
other fam ily members or a mechanic molded seat into which the rider can
can drive the car. lodge securely. Weight lifting can be
done from a seated position on the
Sports and Recreation floor. 6 t ,62
Numerous adaptations in equipment
and technique enable many individu-
als with unilateral and bilateral leg
Summary
amputations to engage in a wide vari- Adults and children with amputations
ety of sports and other pastimes.4 3 and limb deficiencies can accomplish
many personal activities without
Unilateral Amputation prostheses. Reasons for not wearing
Many people with amputations prostheses include the inordinate ex-
choose to swim and scuba dive with- ertion of walking with prostheses, a
out a prosthesis, but all swimmers preference for being unencumbered
must have a means of moving from by devices, or because the person is
the dressing room to the water's edge, not aware of financially, mechanically,
Figure 8 This adolescent with quadri-
membral congenital limb deficiencies pro- such as by hopping or using crutches. or cosmetically acceptable options.
pels his wheelchair using the push rims re- Swimming provides superb recreation Those with unilateral or bilateral
positioned medial to the t ires. Note also as well as good exercise. 58 Agile pa- upper limb amputations can be
the absence of footrests. tients can play several sports while guided to select clothing that is easy
balancing on crutches, fo r example, to don witJ10ut prostheses. The clinic
buttock to the other in a diagonal kickball and soccer. Other sports that team should encourage the child with
do not require the use of a prosthesis bilateral upper limb deficiencies to
manner to maneuver from one sur-
include mountain climbing, skiing, capitalize on the tactile and prehen-
face to the next. Another option is a
and sky diving. 39•61 ' 62 Hiking over sile capabi(jties of the feet to develop
series of sturdy boxes of graduated
hilly terrain can be accomplished with proficiency in dressing as well as writ-
height leading from the floor to the
the aid of a pair of long poles, ening, feeding, and other skills. At all
wheelchair seat. The person shifts
abling the climber to swing through ages, the teeth are useful for grasping.
from one box to the next with sup-
the poles. Three-track skiing involves Many nonprostJ1etic techniques en-
port by the buttocks and hands. 5 9 •60
using a single ski w1der the intact able adults and children to complete
Some who can tolerate weight
lower limb and a pair of ski poles fit- grooming and hygienic care and eat a
bearing through the ends of the am- varied diet gracefully. Writing and us-
ted with rudders distally. Skydiving
putation limbs, such as a person with ing a keyboard, importa nt for school
requires the use of a sturdy harness
bilateral Syme or knee disarticula- securing the torso. and vocations, can be done with sim-
tions, can walk either unassisted or ple adaptation of basic implements
with the support of short canes or Bilateral Amputation and thoughtful selection of comput-
crutches. Others may find a cart26 or Swimming is popular with some peo- ers and other equipment. Virtually all
low platform on casters suitable for ple having bilateral amputation who homemaking duties can be managed
scooting about the home, with the use their upper limbs as the power without prostheses, sometimes bor-
hands used for propu lsion. 59 Such a source. The water enthusiast can ob- rowing techniques developed for peo-
vehicle can be used in areas too nar- tain a wet suit or swim fins to fit the ple with hemiplegia. A wide range of
row for a wheelchair to pass. residual limbs. A plastic wheelchair is games, sports, musical endeavors, and
In an emergency, the person can ideal for beach use. Many activities other recreational pursuits are within
negotiate stairs by sitting on the top popular with people with paralysis the compass of those who do not
stair, then lowering the trunk. De- also suit individuals with leg amputa- wear prostheses.
scent is controlled with the hands, tion who use a wheelchair. The seated Similarly, children and adults who
which are placed on the tread or ban- individual can enjoy tennis, badmin- do not wear lower limb prostheses can
ister. Climbing stairs in this fashion is ton, basketball, bowling, hockey, 58 and learn suitable clothing and safe bath-
more difficult but is fortunately less dancing. Other athletes play while sit- ing procedures. Alternatives to pros-
likely to be required in emergency sitting on the floor. Additional recre- thetic locomotion include crutches,
uations. ational pursuits suited to those with hopping and pivoting, and the opera-

Chapter 59: Reh abilitation Without Prostheses 753
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Publishing &Communications, 1989. 52. Gonzalez EG, Edelstein JE: Energy lower-limb amputees rehabilitated
46. Julavits J: Her sights are always high. expenditure during ambulation, in with crutches and prostheses. Med Biol
Times Union. Jacksonville, FL, Sunday, Downey and Darling's Physiological Eng l974;12:519-523.
March 17, 1996. http://www.amp- Basis of Rehabilitation Medicine, ed 3. 58. Karacoloff LA, Hammersley CS,
info.net/joyce.htm Boston, MA, Butterworth-Heinemann, Schneider FJ (eds): Lower Extremity
2001, pp 417-447. Amputation: A Guide to Functional
47. Edelstein JE: Musical options for
upper-limb amputees, in Lee MHM 53. Fisher SY, Gullickson G Jr: Energy cost Outcomes in Physical Therapy Manage-
( ed): Rehabilitation, Music, and Human of ambulation in health and disability: ment, ed 2. Gaithersburg, MD, Aspen,
Well-Being. St. Lou is, MO, MMB Mu- A literature review. Arch Phys Med 1992.
sic, 1989. Rehabil 1978;59:124-133.
59. Engstrom B, Van de Ven C (eds): Ther-
54. Ganguli S, Bose KS, Datta SR, Chatter- apy for Amputees, ed 3. Edinburgh,
48. Melendez T, White M (eds): A Gift of
jee BB, Roy BN: Biomechanical ap- Scotland, Churchill Livingstone, 1999.
Hope: The Tony Melendez Story. San
proach to the functiona l assessment
Francisco, CA, Harper & Row, 1989. 60. Holliday PJ (ed ): Nonprosthetic care,
for use of crutches for ambulation.
49. Narang IC, Mathur BP, Singh P, Jape Ergonomics 1974;17:365-374. in Kostuik JP, Gillespie R (eds): Ampu-
VS: Functional capabilities of lower tation Surgery and Rehabilitation: The
55. Erdman WJ II, Hettinger T, Saez F:
limb ampu tees. Prosthet Orthot Int Toronto Experience. New York, NY,
Comparative work stress for above-
l 984;8:43-51. Churchill Livingstone, 1981,
knee amputees us ing artificial legs o r
50. Kerr D, Brunnstrom S (eds): Training pp 233-257.
crutches. Am J Phys Med 1960;39:
of the Lower Extremity Amputee. 225-232. 61. Kegel B: Physical fitness: Sports and
Springfield, IL, Charles C Thomas, 56. Ganguli S: Analysis and evaluation of recreation for those with lower limb
1956. the functional status of lower extrem- amputation or impairment. J Rehabil
51. Waters RL, Perry J, Chambers R: En- ity amputee-appliance systems: An Res Dev Clin 1985 (suppl 1):1-125.
ergy expenditure of ampu tee gait, in integrated approach. Biomed Eng 1976; 62. Kegel B (ed): Sports for the Leg Ampu-
Moore WS, Malone JM (eds): Lower 11 :380-382. tee. Redmond, WA, Medic, 1986.

Additional Resources
Ability magazine Eastern Amputee Golf Association
1001 W. I 7'h Street 2015 Amherst Drive
Costa Mesa, CA 92627 Bethlehem, PA 180 l 5
http://abilitymagazine.com http ://www.eaga.org
Adaptability catalog Everest & Jennings Avenue catalog

P.O. Box 515 3233 East Mission Oaks Blvd
Colchester, CT 06415-0515 Camarillo, CA 93012
Fashion Able for Better Living catalog
Alberta Amputee Sport and Recreation Association
5 Crescent Ave
http://www.aasra .ab.ca
Rocky Hill, NJ 08553
American Academy of Physical Medicine and Rehabilitation
Maddak Inc catalog
Directory of Sports Organiza tions fo r Athletes with Disabilities
Pequannock, NJ 07440
http://www.a a pm r. org/condtreat/ath Ietes3. htm
Mainstream magazine
American Amputee Soccer Association P.O. Box 370598
http://www.ampsoccer.org San Diego, CA 92 137
Amputee Coalition of America http://www.mainstream-mag.com
900 East Hill Road, Suite 285 National Amputee Golf Association
Knoxville, TN 37915 11 Wal nut Hill Rd.
http://www.amputee-coalition.org Amherst, NH 0303 l
http ://www.nagagolf.org
Amputee Golfer Magazine
http://nagagolf.org/magazine.htm National Sports Center for the Disabled
P.O. Box 1290
Applied Technology for Independent Living catalog
Wi n ter Park, CO 80482
4732 Nevada Aven ue North http://www.nscd .org/
Crystal, MN 55428
National Wheelchair Basketball Association
Canadian Ampu tee Sports Association http://www.nwba.org
http://www.interlog.com-ampsport/can_amputee.htm l
One-Hand Typing Tutor
Canadian Association for Disabled Skiing http://home1.gte.net/bharrell
P. 0. Box 307
Kimberley, BC VIA 249 Online Sports Links
http://www.activeamp.org
Canada
http://www.disabledskiing.ca/ Special Living magazine
Post Office Box 1000
Challenged Athletes Foundation
Bloomington, IL 61702
2148-B Jimmy Durante Boulevard
http://special living.com
Del Mar, CA 92014
http://www.challengedathletes.org/caf/ Sport for Disabled Ontario
1185 Eglinton Avenue E
CLEO Living Aids catalog Suite 102
3957 Mayfield Road Toron to, Ontario M3C 3C6
Cleveland , OH 441 2 1 Canada
Disabled Sports USA
http://www.sportsfordisabled.ca
45 1 Hu ngerfo rd Drive, Suite 100 Sport 'n Spokes magazine
Rockv ille, MD 20850 2 11 1 East High.land Ave nue, Suite 180
http://www.dsusa.org Phoe nix, AZ 85016
http://www.pvamagazines.com/sns/
Wheelchair Sports, USA
http://www.wsusa.org

Special Considerations: Consumer
Movement
Mary P. Novotny, RN, MS
Introduction
The current situation of professionals as the beginning of comprehensive re- process. The impact of self-advocacy
caring for amputees is a relatively new storative efforts. is demonstrated by the increased
phenomenon that developed in the By shifting the focus from d isabil- availability of patient-oriented educa-
last century. Substitutes for limbs ity to abilities, amputees became val- tional literature, whkh represents a
were first made by amputees them- ued consumers of goods and services, shift from the previous focus on pub-
selves or by their family members to as well as inventors who sought solu- lications pertaining to device technol-
help rebuild their fragme nted body tions to improve their lives. Amputees ogy, case studies, and research.
image and self-esteem. Later, prosthe- seeking better outcomes began advo- While the amputee consumer
ses were made by tradesmen such as cating fo r themselves out of personal movement was occurring, health care
harness makers, armorers, carpenters, and economic necessity. The amputee was changing from a paternalistic
consumer movement exemplifies the medical model to a profit-oriented
or blacksmiths as an extension of
need to grow beyond the Joss of a business model. To improve profit-
their other work. Finally, prostheses
limb. Frankl1 explored this reality in ability, insurance companies and
were made by skilled craftsmen who
Man's Search for Meaning, which de- managed care organizations are at-
ultimately earned degrees, certifica-
scribes self-transcendence as the in- tempting to replace professional deci-
tions, and licenses for the develop-
herent characteristic of humans to sion making with tight regulations,
ment of prostheses. Cmrently, there price controls, and low-bid contracts,
reach beyond themselves and find
are organizations for advancing the which are often in conflict with mini-
meaning for their lives through their
business of developing prostheses, search. Frankl believed that people mal standards of care. Reductions in
providing continuing education, lob- transcend difficulties by giving and benefits have fo rced health care pro-
bying for reimbursements, and regu- receiving care, appreciating the world fessionals into the dilemma of trying
lating the various aspects of pros- around them, accepting things that to provide quality care with fewer re-
thetics. cannot be changed, and through cre- sources. Without adequate funding,
Extraordinary improvements in ative works such as deeds, occupa- many amputees do not have access to
surgical techniques, prosthetic tech- tions, and relationships. So it is with the more technologically advanced
nology, and rehabilitation efforts have consumers seeking to adapt to change prostheses.
considerably changed many aspects of and perhaps better themselves in the This chapter (1) summarizes the
limb loss and rehabilitation. Indeed, process. evolution of amputee care, (2) re-
prostheses have evolved from crude In technologically advanced North views how developments by amputee
supportive tree branches to techno- America and Europe, consumerism consumers have changed the pros-
logically complex devices made of has developed in response to social thetic industry, (3) explains tl1e needs
lightweight flexible materials, often and cultural changes, information of amputees for adaptation, including
controlled by microprocessors and/or and technological advances, and shift- acceptance of an altered body image,
myoelectric controls. With the advent ing health care economics. Consum- (4) reviews support programs,
of adequate prostheses and rehabilita- erism coupled with the information (5) discusses organizational models,
tion programs, amputation no longer eJ\.'Plosion substantially changed the and (6) summarizes the roles of
needed to be labeled as a failure to role of the amputee from victim to a trained peers and health care profes-
preserve a limb, but could be viewed participant in the decision-making sionals in supporting amputees.

Evolution of Amputee Consumerism fanction. The willingness of these in-

dividuals to challenge the status quo,
Care and Prosthetics Impetus to Social Change
and their zeal for devices that would
Historically, limb deficiencies and dis- By the early 1900s, there was marked make them more able than disabled,
abling conditions were fraught with improvement in the survival of am- truly revolutionized prosthetics.
shame, guilt, and fear. Babies with putees. Persons injured in war or in- Bob Radocy was determined to
congenital limb deficiencies were of- dustrial accidents had better immedi- make his life as normal as possible af-
ten kilJed or ostracized because they ate care and more rapid evacuation to ter losing his ru·m in an automobile
were perceived as being liabilities or hospitals and rehabilitation centers. accident when he was 21 years old.
spiritually unclean. King Montezuma Centers with critical care units and Having studied biology, engineering,
II, an Aztec ruler, established an area trauma services saved many lives and and drawing, Radocy began sketching
for degrading the disabled within the salvaged function of residual limbs the kind of prosthesis he wanted
royal zoo and botan ical gardens. Am- for thousands of people. Improved while still lying in his hospital bed.
putation has also been used as a judi- health care, industrialization, and When he was told that the standard
cial punishment in several cultures- postwar developments increased the split-hook would replace his arm, Ra-
a practice that continues today. number of amputee consumers who docy knew that no single device could
Throughout medical history, am- lobbied for services. Many amputees serve his multiple needs. He was
putation was only performed as a last benefited from federal and state reha- handicapped by the available technol-
resort to save lives. Armorers fabri- bilitation programs such as the Veter- ogy. He began thinking that the de-
cated artificial limbs at the request of ans Health Administration, Medicare, sign criteria were insufficient, and he
knights and royalty to camouflage lost and Medicaid. A program to support decided to try to improve the situa-
limbs. Queen Vishpla was fitted with research and development in pros- tion. This decision changed his life
an iron leg to enable her to walk and thetics was launched by the National and the lives of thousands of upper
return to battle.2 Goetz Von Berlich- Academy of Sciences under the aus- limb amputees who benefit from the
ingen (1480-1562), a German merce- pices of the Veterans Administration. multiple components that he de-
nary knight, was provided with ru1 In addition, expansion of health in- signed. What began as a personal
amazing mechanical prosthetic hand surnnce coverage allowed prostheses search for a better product resulted in
as was Admiral Barbarossa, who to be more available to amputees. vastly improved upper limb terminal
fought with the Spaniards in Bougie, Unfortunately, by the end of the devices, and changed the way ampu-
Algeria in 1512.3 1980s, efforts to control rising health tees perceive themselves and their
War often triggered government care costs through mruiaged care im- abilities.
intervention to address the needs of posed serious funding restrictions. Bruce Kania lived most of his life
veterans whose amputations resulted New policies limited consumer with the frustration of meshing an
from the improved destructive power choices and access to appropriate energetic lifestyle with the limitations
of war and evolving medical tech- health care despite progress in re- of a prosthesis that did not meet his
niques. The first large-scale attempt at search, professional care, and technol- needs. As an active outdoorsman, Ka-
prosthetic replacement of limbs sup- ogy. These changes further stimulated nia decided to seek better solutions
ported by the United States govern- the amputee consumer advocacy for his prosthetic problems rather
ment was the Great Civil War Bene- movement. than being limited by the available
faction, which provided prosthetic Possibly the issue that had the devices. Eventually he worked with
devices to veterans of the Union greatest influence on amputee con- researchers to design a fabric-covered
Army in the American Civil War. sumerism was the perception of many gel socket liner that allowed him to
InitialJy, European universities be- amputees that health care profession- triple tl1e amount of time that he
gan developing both the art and sci- als were perceived as exper ts and the could walk comfortably. The success
ence needed for the development of amputee was supposed to remain du- of this type of gel liner has benefited
prostheses. This process, however, tifully subservient. This traditional thousands of amputees. In addition,
Lacked a thorough understanding of view of medical care seemed an Kania donates some of the proceeds
the underlying psychological needs of anachronism in the era of consumer from royalties on the liner to improve
the amputee. Indeed, many curricula empowerment and activism. the quality of life for amputees.
pertaining to the development of Cru·l Caspers lost his leg in an acci-
prostheses still Jack a consideration of Individual Consumers Who dent while he was in high school. Se-
the amputee's alterations in self- Advanced Technology vere tissue damage made wearing a
image as they struggle to regain per- Amputees soon began seeking ways to prosthesis botl1 difficult and uncom-
sonal integrity and balance whi le af- improve their lives. Many wanted fortable. ln his search for a more
fected by changes that they cannot more than the rudimentary replace- comfortable and functional socket,
control. ment devices that provided limited Caspers became a certified prosthetist

Chapter 60: Special Considerations: Consumer Movement 759
and orthotist. His fascination with devices themselves or commissioned a Prosthetics organized a reception
socket environments coupled with his craftsman to build something to their with members of Congress that al-
inventive mind led Caspers and his specifications. lowed amputees to demonstrate the
team to discover the resilient cushion-
necessity of their prostheses in lead-
ing properties of urethane, which he Development of Amputee ing productive and independent lives.
used to create an interface and socket Support/ Advocacy This unified response resulted in a de-
design that controls the socket envi- Programs feat of the proposed cuts in funding.
ronment for the amputee wearer.
The growing demand for resources, The final result was the development
Van Phillips was 21 years old when
information, and advocacy for ampu- of functional levels that provided
his leg was severed just above the an-
tee consumers prompted the develop- guidelines for prosthetic prescriptions
kle. Because he had been so active, he
ment of several consumer organiza- based on rehabilitation potential of
felt handicapped and frustrated by the
tions. War Amputations of Canada amputees, rather than general classifi-
available unresponsive prosthetic feet.
He began a search for a better alterna- was the first nationwide amputee cations based on age, disease, or pre-
consumer organization in North vious limitations.
tive with the assistance of an aerospace
engineer who had experience with America. This organization became a As consumer problems with access
composite materials. They analyzed model for other organizations based to and funding for appropriate care
the requirements for a prosthetic foot on its success with regard to educa- and devices increased, advocacy was
and ankle unit. This led to the design tion and empowerment in areas such officially added to the mission of the
of a composite carbon fiber-resin ma- as veterans care and advocacy for ACA in 1995. To address the expanded
terial, which they formed into an children affected by amputation. mission, the ACA began advocating
L-shaped foot and ankle. When Phil- Since their first networking meet- for ftmding to establish a national in-
lips tested the spring-like foot/ankle ing in 1986, the leaders of amputee formation center to handle requests
unit by applying weight, the force support groups in the United States for information related to limb loss,
compressed the spring and some force recognized the serious need for a uni- train peer visitors, and collect data.
was returned at toe-off, putting more fied voice for amputee consumers. In 1997, the ACA opened the Na-
spring into his step. This design be- Their goals were to strengthen scat- tional Limb Loss Information Center
came the forerwmer of the currently tered support group programs, and to (NLLIC) in Knoxville, Tennessee, un-
available dynamic response feet. centralize resources for more effective der a collaborative agreement with
Competitive participants with high support and dissemination of infor- the Centers for Disease Control and
expectations were involved in pro- mation to amputee consumers. This Prevention (CDC). Touted as a model
moting the development of func- need led to the formation of the Am- for other agencies, the NLLIC was the
tional, high-impact prosthetic devices putee Coalition of America (ACA), first collaboration between a private,
made of duxable lightweight materials which was incorporated in 1989. The nonprofit o rganization and the CDC.
capable of withstanding the stresses ACA organized formal programs to In 1999, a research partnership be-
of athletic competition. The demands fulfill its mission of outreach, educa- tween the ACA and Johns Hopkins
of athletic amputees provided the in- tion, and empowerment by develop- University to evaluate data on limb
centive for new product development ing resouxces for amputee consumers, loss was also funded by the CDC.
and the expansion of the market for establishing a network of trained peer Through implementation of these
prostheses. volunteers, and assisting local ampu- programs, the ACA overcame fears
The common thread with these in- tee support groups. that numerous agencies and organiza-
ventors was a desire for improvement By 1993, the ACA faced a new tions would not be able to collaborate
of the status quo. Each one dem- challenge. Proposed cuts in Medicare on a national level. Continued fund-
onstrated the potential for positive funding would severely limit reim- ing and success will depend on main-
adaptation based on individual char- bursement for prostheses and care of taining credibility, continued com-
acteristics including personality, amputees. The elimination of reim- munication with multiple agencies
self-image, life experience, and avail- bursement for necessary services and and organizations, producing
able resouxces. Unlike individuals prostheses would affect both ampu- mission-oriented results, and main-
who focus on the negative aspects of tees and providers. An aggressive col- taining leadership of visionaries who
limb loss, successful individuals con- laborative response was the only feasi - are willing to change the status quo.
centrate on available strengths and re- ble solution. The ACA coordinated a
sources, and engage in adaptive rather campaign to write to federal policy
than maladaptive behaviors. In some
Theories on Body
makers and began an aggressive edu-
ways these resourceful inventors are cational program to promote the ben- Image and Adaptation
comparable to amputees of previous efit of prostheses. The ACA and the Traditionally, medical care has fo -
centuxies who either made prosthetic National Office of Orthotics and cused on the physical issues of ampu-

approach w1ites amputees and profes-

sionals as partners in planning and
achieving successful outcomes. Work-
ing together, the rehabilitation team,
medical team, and support team can
address biopsychosocial issues and
promote positive adaptation.
Most literature pertaining to am-
putee rehabilitation focuses on physi-
cal aspects and issues pertaining to
prostheses. Some theorists, however,
including Sister Callista Roy, who
proposed the Adaptation Model, sug-
gest an integrated model of practice
Support Team that highlights the relationship of bi-
Family,
Support Agencies, ologic, psychological, and social as-
Employers, pects of health as they relate to indi-
Payors ,
Community vidual adaptation to life changes. 4
The Roy Adaptation Model views hu-
mans as biopsychosocial beings,
stressing the interrelationships be-
tween an individual's physical, psy-
chological, and social well-being. An
individual's response to stimuli in the
environment is based on four modes:
physiologic needs, self-concept, role
Figure 1 Interdisciplinary consumer care model. function, and interdependence. In-
dividuals have the capability of
adaptive/positive response only when
the stimuli are within their zone of
experience. Individual responses are
maladaptive when stimuli are outside
-
.... - - . . . , ®_
-- ®
,lc"l~elatlonshlp or ' ..- - t heir zone of experience. The goal of
vocational change ~ _
®-. Growth @ R
- ~c,:ea ona.1
- ti
@ ',:2) _ "f\ence
~One of Ex9e health care is to prevent or modify
-Spiritual S
activities @
rc:-,
® f41flllment S ~ maladaptation by adjusting the stim-
411-!o~iioliiii........-....................~.............................~ Death uli, environmental factors, and/or re-
W I ness I§\ Developmental @·relocation
~ changes rc;,,. sources to be within the patient's zone
®-menopause ._§;-@physical injury
S -puberty
@ure stressors: @-Aging
of experience (Figure 2) . In a similar
- ..., Zone et\e~ - "':"'.""" ,... - - , manner, transcendence theorists fo-
..,.; _ of ~ 9,... &"Chrome illness, - @rdi'1llrce @-Physical disability.
cus on the balance between physical
® -body image
changes
@-grief loss
and emotional health as determinants
5
of outcomes in coping with illness.
LinkiJ1g several of these concepts re-
Figure 2 In this adaptation model, human beings are constantly responding to stimuli
(circled S) along the health/illness continuum (H ). sults in a consumer-centered health
care model that integrates the medi-
cal, rehabilitation, and social net-
works with the patient/family unit to
tation, and prosthetics focused on de- putee consumer. The importance of address the complex physical, psycho-
vices. Neither discipline adequately keeping the amputee consumer at the logical, and social needs associated
addresses the psychosocial aspects of center of the health care team is sup- with limb loss.
amputation, which profotmdly influ- ported by body image and adaptation Any alteration in body image di-
ence outcomes. A multidiscipljnary theories. With these models, t he focus rectly affects an individual's percep-
team that includes consideration of is shifted to reconstruction and re- tions of attractiveness, capability, and
biologic, psychological, and social in- habilitation following amputation normality. The factors involved in re-
fluences can enhance outcomes by ad- rather than disability and disruption sponse to limb loss are complex and
dressing the holistic needs of the am- of physical integrity (Figure 1). This unique to each individual. Adaptation

to limb loss depends on a variety of their limb loss than amputees who do role modeling and peer support to in-
factors including the meaning of the not have these types of support. crease skill mastery and confidence in
loss, physical changes smrounding If an amputee lacks adequate in- problem solving, adaptive function-
the loss, level of self-esteem, premor- formation, support, or coping skills, ing, and resumption of sports, recre-
bid personality, and associated envi- their problems may be compounded. ation, and other pursuits.
ronmental, psychological, and social New amputees have no reference Many amputees also need a pro-
resources. These complex issues are point for the experience and often gram of physical conditioning to
indjcators of whether an amputee will perceive disabiljty in an excessively bwld self-esteem, gain independence,
approach or avoid a challenge, be a negative manner when confronted and promote positive outcomes.
passive or active participant in care, with alterations of body image and Strength training exercises should be
and have an optimistic or pessimistic functional losses. Exposure to foreign included in the preoperative and
attitude towards life changes. Knowl- terminology, baffling technology, and postoperative plan of care. Regaining
edge of body image and adaptation unfamiliar caregivers can also be neg- balance and strengthening areas of
theories provides a perspective that ative factors. Fear of the unknown is weakness ensme that amputees do
can aid professionals in understand- an issue because so many of the stim- not become predisposed to problems
ing some of the issues related to pro- uli bombarding the new amputee are of immobility, which complicate re-
moting positive adaptation to limb outside of his or her zone of experi- habilitation. To maintain focus and
loss. ence. Furthermore, the amputee's commitment, goals should focus on
According to Schilder,6 body image need to regain control and participate individual strengths, lifestyle, and in-
is the mental picture of one's body in decision making is often perceived terests. When there is a rapid return
that is formed as a tridimensional en- as unimportant by health care profes- to normal activities, the amputee is
tity and involves interpersonal, envi- sionals. Lacking adequate resources less likely to experience prolonged
ronmental, and temporal factors. He and support, these individuals may depression and dependence. By avoid-
describes the development of body suffer from low self-esteem and fail to ing delays and planning immediate
image as a dynamic process that is integrate positive changes, recon- follow- up with knowledgeable staff to
constantly affected by physical, psy- struct a new body image, and regain review progress, the amputee should
chological, and social factors. Schilder their previous functional status. have maximum opportunity for a
suggests that people continually con- Without intervention and support to
successful outcome.
struct, dissolve, and reconstruct their change, maladaptive behaviors can
body image as well as the images of lead to mental and physical handicaps
others. He also suggests that body im- even in patients who had a medically Adaptation and
age extends into the space around the successful amputation. Social Support
individual. According to trus theory, a For optimal adaptation, amputees
firm object, rigid in its connection to should be assessed witl1 particular at- Amputees often indicate that al-
the body, can be incorporated into the tention to perception and meaning of though health care professionals pro-
body image. In that way, a prosthesis limb loss, roles, self-concept, and in- vide medical information, they were
can be incorporated into a recon- terdependence. Family members and aided the most by trained amputees.
structed body image. significant others should be included These trained amputee peers not only
This concept was confirmed in a in the assessment. Needs for educa- understand the complexities of deal-
study at the University oflllinois with tion and support must be addressed ing with a limb loss but are role mod-
children and adolescents who were so that the amputee and family mem- els during a time of stress. In addition
an1putees. In this study, the amputees bers can be provided with useful in- to dealing with the i11itial shock of
portrayed themselves with prosthetic formation, strategies for effective losing a limb, an amputee must re-
devices, crutches, and even in wheel- functioning, social support, and an learn many fundamental tasks. He or
chairs when requested to complete a opportunity to participate in deci- she can be greatly aided by another
self-portrait. Because adaptation to sions regarding future care and needs. person who has succeeded in accom-
change is based on an indjvidual's An important aspect of positive plishing the same goals that the new
need to develop, and later discard, the adaptation is to use disequilibriwn, amputee is attempting to address.
series of different selves, limb loss can the initial reaction to stress, as a mo- Routine functioning is often taken for
provide the opportunity to redefine tivator to learn new, more helpful be- granted, but the new amputee must
the concept, to learn new behaviors, haviors. During this period, it is im- struggle to adapt to the disruption of
and to master new tasks.7 Therefore, portant that professionals and family functioning caused by loss of a limb.
amputees who are presented with a members express positive attitudes The usefulness of mutual, self-help
reconstructive framework with emo- regarding possibilities, rather than support groups has been widely rec-
tional support, physical training, and limitations. Although amputees bene- ognized, but has not been rigorously
education are better able to adapt to fit from professional help, they need evaluated by statistical methods in

762 Section [V: Management Issues
controlled clinical trials. A major rea- social support was associated with sion from receiving support to giving
son for this lack of documentation is lower serum cortisol concentrations support .
the difficulty in completing a scientif- in women with metastatic breast can-
ically rigorous study on such a com - cer- a result that suggests healthier
plex, mult ifactorial issue as limb loss. neuroendocrine functioning . A sam-
Support Programs
Challenges in the design and comple- ple of 101 breast cancer survivors Assum ing that support is beneficial
t ion of studies to assess support of younger than 50 years demonstrated a for those undergoing major life
amputees include adequately control- positive correlation between per- changes, it is useful to exam ine mod-
ling variables, developing appropriate ceived social support and quality of els and programs of support. Support
end points, and correct use of statisti- life. 11 In addition to known somatic services vary depending on their mis-
cal methods to ensure valid conclu- factors, the 10-year prognosis for pa- sion, resources, and location. Thus,
sions. Despite the lack of statistically tients who had a myocardial infarc- although many programs provide in-
validated studies, most professionals tion was adversely influenced by deformation, resources, and peer sup-
understand and accept that support pression an d lack of social support. 12 port, the methods of support and fo -
and education help patients make Other positive correlations have cus differ.
complex transitions. been noted between support and net- The University of Wiscon~in, for
The results of studies of the effec- work size, and between network size example, developed a social support
tiveness of social support in other sit-
an d the quality of life. 11 The interac- network for b reast cancer patients
uations, such as cancer and heart dis-
tion between personal and collective who communicate using computers.
ease, are available and would likely
resources was studied among 230 kib- Participants indicated that anonymity
apply to the support of amputees.
butz members in Israel. The combi- within t he support group fostered
One study used the Roy Adaptation
nation of personal and collective thoughtful interaction and enabled
Model to test the assumption that
resources is useful in avoiding func- communication in ways that would
support leads to better adaptation to
tional limitation and becomes valu- have been more difficult in a face-to-
change.8 This study examined adapta-
tion of women to breast cancer and
able in helping with recent life events. face con text. 15 On a more global
When stress affects social f1rnction ing, scale, computers connect millions of
their participation in support groups.
Data from structured telephone interpersonal resources facilitate the mobi- people through e-mail, chat rooms,
views with 70 women who partici- lization of whatever coJlective re- and informational websites. The ACA
pated in group social support and sources are available. 13 is staffed with information specialists
education on breast cancer were ana- Studies have shown a direct rela- to respond to requests fo r resources.
lyzed. Most women reported helpful tionship between religious involve- In addition, trained peers associated
adaptive physiologic, self-concept, ment and/or spirituality and positive with the ACA are available by tele-
role function, and independence with health outcomes such as mortal ity, phone when local peer volunteers are
participation in a support group fol- physical illness, mental illness, and not available. Common interests in
lowing treatment of breast cancer.8 quality of life. Informing patients of sports and recreation also have led to
Other studies demonstrate that social available resources for spiritual care the development of numerous sports
suppor t and quality of life are posi- can provide reassmance, limit isola- and recreational programs for ampu-
tively correlated in breast cancer pation, and facilitate recovery. Pastoral tees seeking instruction, information,
tients. A 6-month randomized, con- care. departments in many hospitals and peer support. The presence of a
trolled study showed that patients have access to commw1 ity resources peer, role model, and/or guide seems
being treated for breast cancer who that can make a valuable contribution to benefit amputees by reducing de-
received early psychosocial support to the holistic care of patients. 14 pression, decreasing anxiety, and rein-
had a high acceptance of support and Thus, research of a variety of con- forcing positive adaptive behaviors.
improved quality of life compared ditions involving major life changes Some support groups are indepen-
with patients in the cont rol group demonstrates that multidimensional dent, but others work with profes-
who did not receive the support. 9 support is highly beneficial to many sionals to increase visibility and to
Psychological state appears to be individuals. Benefits of communicat- complement, rather than appear to
one of the best indicators of adjusting with others who have similar compete with, rehabilitation teams.
ment by cancer patients. Other find - problems incl ude obtaining advice on For example, some parent organiza~
ings indicate that the social contacts adapting, shifting focus away from tions, special camps for children and
and social suppor t from one's partner, their own illness by helping others, adolescents, veterans' organizations,
family, friends, relatives, and medical and gaining insight as to what to ex- and social clubs are cosponsored by
professionals are important for sur- pect. In many instances, motivation rehabilitation cen ters and clinics. (See
vival. 10 A study at Stanford University for seeking social support appeared to sidebar "Amputee Support Groups"
demonstrated that greater quality of be a dynamic process with progres- on page 769.)

Chapter 60: Special Con siderations: Consumer Movement 763
This model is particularly effective made available to the amputee and sible. Without support and informa-
in establishing visibility and main- family members as soon as possible, tion, families become maladapted to
taining positive relationships between regardless of whether the involvement an extent that affects the child
amputee consumers and profession- is through one-on-one peer contact, throughout his/her lifetime. 19
als. Although consumer groups can be group programs, or support related to Family support groups formed be-
supported and guided by profession- sports, recreation, or hobbies. cause parents of children with con-
als, these groups should not be run by Although all amputees need sup- genital limb deficiencies wanted op-
nonarnputee professionals. Profes- port, the specific needs for informa- portunities to share their experiences.
sionals involved in programs should tion may vary by age and gender of the Many parents lacked information and
not have the expectation of referrals amputee. When a trauma center and support at the time of the child's
and endorsements. This situation can the Veterans Hospital in Puget Sound, birth. They lacked ilie ability to ex-
lead to justifiable fear and anxiety \I\Tashington, questioned amputees, plain ilie deficiency to fam ily and
among other professionals that the they identified their main interests as friends. They sought information on
support group is merely a feeder or- ( 1) fit of the socket with residual limb, how to address the child's questions,
ganization, which can lead to compet- (2) mechanical functioning of the teach tl1e child to handle questions,
itiveness and program failure. prosthesis, (3) nonmechanical quali- introduce their child into a new
Discussions witl1 patients and fam- ties, and (4) advice about adaptation school system, and to prevent teasing
ilies should not include endorsements to life with a prosthesis with support from other chjldren. These families
of devices and services. This is adver- from others. 16 Similar comments have are concerned about available services
tising, not education and empower- been documented by other surveys in and the benefit of interdisciplinary
ment. The goal of advocacy and sup- which amputees who acknowledged treatment centers. Knowledgeable
port is to teach amputees how to the assistance of health care profes- parents recognize that a symbiotic re-
obtain valid information and how to sionals reported being helped most by lationship between the professionals
make choices, railier ilian telling peers who shared the experience of and families is helpful in identifying
them where they should go for care or limb loss. 17' 18 developmental problems, setting ap-
service and what types of specific propriate goals, and implementing
products should be requested. Fear Early Childhood solutions. 20 -22 Health care profession-
regarding competition can be mini- Children with congenital limb defi- als also learn from the children and
mized if both amputee conswners ciency inhabit the only body they parents. Parent groups raise public
and professionals recognize that the have ever known and it seems normal awareness, provide education about
choice is always in the hands of the for them. Their world is dominated limb Joss, and serve as models for
amputee consumer. Competent pro- by parents, family, and friends who adapting to life with disabilities. Some
fessionals have nothing to fear when generaUy attempt to treat them as groups have newsletters or share in-
conswners have realistic information normal or who shield them from any formation over the Internet.
and expectations. emphasis on the missing limb. These Responses to parent groups are
children have minimal perception of generally very positive. Successful
their limb differences until they are models of support include informal
Developmental confronted by peers and the p ublic. gatherings when families and their
Stages and Initially it is parents who experi- children meet in a clinic setting or a
Adaptation to Limb ence shock, the loss of their dream of home. These social outings are some-
a perfect chi ld, guilt about the limb times coordinated by nurses, social
Loss difference, depression, and sometimes workers, and/or ilierapists. Regardless
The need for psychosocial support for even rejection of ilie child. To help of the support group, parents can es-
aU amputees, regardless of age or gen- parents and other families to adapt, tablish long- term, beneficial relation-
der, is supported by overwhelming they need counseling, information, ships with other families.
evidence. Support is needed to ad- and peer support to address current
dress the profound changes in body questions as well as future concerns. Adolescence
image, self-esteem, role functioning, Experienced peers help the family Many adolescents and young adults
and interdependence that are associ- recognize the normalcy of their con- adapt more readily to limb loss than
ated with the loss of a limb. A balance fused feelings and focus on ilie overall adults, even in the presence of medi-
between medical rehabilitation and health of their child. A peer group can cal complications such as cancer.
social support is essential to achieving demonstrate that the missing limb in Some of the greatest cbaUenges of
a positive adaptation to Jimb loss. no way dimjnishes the worth of the teenagers revolve around the need to
Physical rehabilitation complemented child and that, altl10ugh there may be be accepted within a society that
by psychosocial support is vital and some limitations, child amputees places a high value on physical at-
cost effective. Support should be should be treated as normally as pos- tributes and beauty.

Although many teenagers shy away mellitus, vascular problems, and heart Factors Contributing
from formal involvement with sup- disease compound the patient's physi-
port groups, they may interact with cal adaptation. Psychological and
to the Success of
peers in sports, recreation, camps, social aspects are also dramatically af- Support Groups
and other activities that focus on fected. Entire families need informa- The results of support programs can
equal participation and indepen- tion regarding pre- and postoperative vary depending on leadership, culture
dence. These activities provide feed- care, skills to assist with rehabilita- of the community, and the presence
back, role model identification, and tion, and emotional suppor t through- or absence of professional support.
promote positive self-image and self- out the experience. In many elderly Although it seems that support
esteern by focusing on abilities rather patients, rehabilitation is complicated groups would flourish as complemen-
than disabilities.
by isolation, lack of social support, tai·y partners to the health care pro-
Although school personnel may at-
and limited financial and social re- fession, many fail within the first few
tempt to be supportive, many are not
sources. The needs of these patients years. Causes of failure include lack of
well informed about positive out-
must be add1·essed immediately. An leadership and inadequate structure
comes and abilities of individuals
with limb loss. This lack of informa- appropriate postdischarge placement to sustain the group, meager re-
tion can lead to overprotectiveness, should be provided until the individ- sources, and failure to market ser-
anxiety, and possibly even reinforce- ual can resume more independent vices. But the greatest obstacle to
ment of negative behaviors. In some functioning. success is underutilization by profes-
situations, adolescents need professionals who either lack the knowledge
sional counseling. A team approach
Significant Others of the importance of support or who
might involve a cotmselor, nurse, or The need for involvement of family perceive amputee consumer advocates
social worker conferring with the am- members is irrefutable. Because fam i- as a threat to their business. Some
putee, their families, and school per- lies are integral to the life of the am- professionals prefer to focus on pro-
sonnel. This approach can reduce putee, they h ave a major impact on viding devices an d fai l to acknowl-
problems by allowing teenagers to adaptation. Families can either pro- edge that the psychosocial needs of
share their feelings and helping mote rehabilitative efforts or enhance amputees ai·e at least as important, if
school personnel assist the amputee isolation, depending on styles of not more so, than limb replacement
in regaining cont1·ol of his/her life.23 comm unication, problem-solving in positive adaptation. Unfortunately,
skills, and social support systems. patients lacking referral to a support
Adulthood Trials of one psychoeducational group or information about such re-
As Gray discussed in Men Are From support group indicate the need for sources as the NLLIC may never
Mars, Women Are From Venus, men adapt to the changes imposed by limb
interventions targeted at the signifi-
and women differ in their desire for loss and therefore never make a com-
cant other. Involved spouses h ad
and response to emotional support. 24 fewer mood d isturbances, and re-
plete adjustment to living life fully af-
Women are more likely to seek sup- ter amputation.
ported greater confidence, support,
port outside of marriage than men; The success of an amputee peer
and satisfaction with their spouses
however, women vary considerably in support program depends on focus-
than those who had not been through
the kind of group they prefer. Some ing on a mission, developing collabo-
the training program. 26
women find church groups most rative partnerships between volun-
Significant others, however, can
helpful; others prefer general support teers and professionals, and
hinder rehabilitation if they reinforce continuous follow-up to assess and
groups. These preferences may relate
to training, the ability to deal with negative behaviors. Criticism and in- improve program outcomes. An orga-
emotions, knowledge regarding em- appropriate advice impair adaptive nization focused on its m ission and
pathy, and communication styles of responses. Some family members find with specific goals is less likely to fail
the interaction. One study reported a it particularly difficult to separate than one trying to be all things to all
lower risk of depression in women their own needs from those of the people. Networking and building alli-
who were socially involved. 25 In con- amputee, thereby giving advice or ances with organizations that address
trast, men who received social sup- criticism that undermines efforts at other needs (eg, sports and recreation
port outside their marriages had an rehabilitation. Early, effective training organizations or funding agencies) is
increased risk of depression. 25 and appropriate support for family far more effective than attempting to
members can promote positive adap- meet all the needs of the amputee
Senior Years tation for the new amputee by dispel- within one organization.
When amputations occur in the eld- ling negative stereotypes, improving The abil ity to develop collaborative
erly, the medical complications of listening skills, and promoting em- relationships ensures that credibility
comorbid conditions such as diabetes powerment rather than dependency. and knowledge about the group

Chapter 60: Special Considerations: Conswner Movement 765
among health care professionals is and/or g1vmg inappropriate advice. administrative functions such as ob-
positive. This cooperation creates an Peer volunteers Learn how to discuss taining financial support, developing
environment of trust and rapport. For their experiences about adapting to newsletters, providing office space and
amputee patients and community daily challenges without giving pro- services, and dispensing materials.
agencies, the inclusion of emotional fessional advice. Through construc- Professionals who are not directly
support, information, and affin native listening an d exploring feelings, involved with support groups can dis-
tion benefits amputees and volun- peers provide emotional support for play literature and resources for am-
teers, and it strengthens linkages be- the amputee facing alterations in putees and families who visit their of-
tween the amputee consumer, the body image, functiona l capabilities, fices and facilities. Many facilities are
community, and the professionals. and social interactions. Unlike profes- developing patient information pack-
Professionals and peer support are sionals w ho have limited time for pa- ets to distribute to new patients. Pack-
perceived as complementary rather tient interaction, volunteers can inter- ets can include information about
than competitive. act with amputees and their families community and national reso urces.
in a variety of settings. Whether the interaction between
Roles of Trained Volunteers The training program covers issues patients and professionals occurs in a
The ACA provides training for volun- that should be referred to a profes- hospital, rehabilitation center, or
teer peers and instructors that covers sional for follow-up, such as possible prosthetic facility, collaboration can
fundamental information on the role litigation, avoidance of endorsements, be advantageous for both support
of peers, communication, and empa- discussions regarding inappropriate groups and professionals. This collab-
thetic discussion of sensitive issues re- sexual and romantic content, and oration is not competitive as it in-
quiring judgment and tact. (See side- other topics that may exceed the ca- volves mutual planning, implementa-
bar "The Peer Visitor" on page 770.) pacity of a volunteer. Training should tion, and evaluation. Support groups
The role of a volunteer is to share ex- review the effects of endorsements for amputees are not intended to rival
periences, information, and emo- and recommendations that can dis- professional care and services; how-
tionaJ support, thus empowering the empower the amputee who may seek ever, they can play a vital complemen-
new amputee and his or her family to answers and solutions from peer visi- tary role in rehabiJitation at no ex-
make their own informed decisions. tors. What works best for one ampu- pense to patients or health care
Trained volunteers can enhance posi- tee is based on a variety of issues; professionals.
tive adaptation and complement therefore, decisions must be consid- Involving the amputee consumers
medical rehabilitation programs for ered on a case-by-case basis as out- as members of the rehabilitation team
amputees. Well-adjusted amputees comes vary. includes devising a system of open
can be role models demonstrating and ongoing communication to dis-
both function and qual ity of life de- Roles of Professionals cuss progress or problems. Any lack of
spite the loss of a limb. Health care professionals are divided resources, 1 information, or support
Amputees focused on returning to in their opinions of the value of am- should be addressed appropriately.
work may receive support from amputee and other self-help groups for The amputee and his or her family, as
putees who are similarly employed. several reasons. Unfortunately, some well as medical, rehabilitation, and
Vocational organizations or others support groups mainly exist to satisfy social support systems, should all
who have a stake in the amputee's the ego of the founder. Other groups contribute as members of the team.
outcome might also play a role. Nu- may have good intentions but use un- SuccessfuJ adaptation is achievable if
merous studies demonstrate that re- trained perso1111el who lack the skills all team members collaborate to es-
turning to work is a positive part of to provide true benefits to amputees. tablish realistic goals, implement re-
rehabilitation. For many individuals, A considerable number of health care quired measures, and continuously
work is related to identity, self- professionals, however, are en thusias- evaluate outcomes.
esteem, respect, and standing within tic supporters of well-managed am-
the community. In addition, work putee support groups with trained
provides social support, companion - visitors that offer genuine benefits to
Summary
ship, role fulfillmen t, and economic their patients. Long before the existence of techno-
gains.27 For proactive health care profes- logically advanced methods and spe-
Training is not intended to turn sionals, numerous opportunities exist cialized health care professionals, am-
peer counselors into psychotherapists to build aHiances with amputee putees acted as their own advocates
or professional problem solvers but to groups. Professionals can serve as and sought solutions to improve de-
help volunteers develop the skills educators, make referrals of new am- vices to allow adaptation to limb loss.
needed to assist other amputees. Vol- putees, provide resources and infor- Many innovative prosthetic compo-
unteers need proper training to Learn mation, and assist with group discus- nents would not exist without deter-
how to avoid excessive self-disclosure sions. They can also help with mined, dissatisfied consumers who

were unwilling to accept discomfort grate consumer needs into prosthetic grams, resources, and techniques to
and functional limitations. In a simj- care, research, and education. assist local groups, national organiza-
lar manner, amputees who were The availability of information via tions can produce high quality educa-
sports enthusiasts helped develop the Internet empowers amputee con- tional pieces, deliver support effec-
lighter weight, resilient, flexible mate- sumers to be involved in decision tively, and educate communities
rials for prostheses that tolerate long- making. Although the literature pre- across the country.
term use in sporting activities. viously focused on technical devices Consumers adapting to a major life-
Amputees who are educated and and research, information written in style change must have readily acces-
advocate for themselves are beginning language understandable by the aver- sible, easily understandable informa-
to achieve better o utcomes than ever age person is now available to ampu- tion and support. Any standard of
before. Advances in medical care and tees and their families. care should include provisions to pro-
prosthetics continue to improve cli1u- Unfortunately, a business model vide educational support services for
cal outcomes. In addition to medical focused on financial results rather amp utee consumers and their fam ilies
advances, the shift in focus from dis- than on patient outcomes is replacing dealing with life changes. A global
ability to abilities is beginning to have the medical model. This shift forces plan to improve access and available
a major impact for amputees. Rather health care providers into the di- services is needed to coordinate re-
than viewing amputation as the tragic lemma of trying to provide high qual- sources around the world. Facilitating
end to an unsuccessful treatment reg- ity care with fewe r resomces. Thus, communication among professionals,
imen, health care professionals can amputees may not have access to the informational resources, and consum-
regard amputation as a key element of most technologically advanced pros- ers could help improve outcomes by
a restorative effort. thetics without appropriate reim- making resources available to those in
Respect and collegiality are chang- bursement. Outcomes research to val- need.
ing the relationship between amputees idate the importance of prostheses Worldwide connections to a vir-
and the role of patient support are tual library and resources facilitate
and health care professionals to that of
needed to help justify the reimburse- access of both consumers and health
a partnership. Unquestioned decision
ment of these products and services. care professionals to current informa-
making by health care professionals is
tion regarding technical resources,
decreasing as empowered amputees
biomedical studies, rehabilitation,
and other consumers actively partici-
pate as members of the rehabilitation
Conclusions and self-help information, prosthetic pub-
Future Directions lications, consmner organizations,
team. Amputee consumers are the
and funding sources. Virtual re-
only team members who interact with To continue to make progress, con- sources have the capability of net-
every health care provider and attend sumers cannot rely on past accom- working consumers across the nation
every office visit, meeting, and ap- plishments. Enforcement of the Amer- or the world, thereby eliminating the
pointment. The changing attitudes of icans With Disabilities Act, continued isolation of consumers, including
health care professionals has the po- access to information and technology, those encumbered by location or mo-
tential for keeping consumers in the and improvement of health care sys- bility problems. As mentioned in
center of the comprehensive interdis- tems around the world require a uni- Prosthetics!Orthotics Research for the
ciplinary health care model. The am- fication of advocacy efforts as well as Twenty-first Century, 28 a virtual li-
putee is the reason for assessment, improved education and information brary should be linked to consumer
evaluation, fitting, technology, and re- and increased outreach. Health care and professional programs, world-
search (Figure 1) . professionals, particularly prosthe- wide research and care centers, and
Professionals in medicine, rehabili- tists, are robbing themselves of their online support groups to address the
tation, and prosthetics can gain in- most effective allies and advocates needs of isolated individ uals who
valuable allies by collaborating with when they avoid involvement with need easy access to resources. Virtual
information centers, support groups, amputee consumers. information on clinical issues, re-
and sports associations that provide Additional work is needed to as- search, technology, and adaptive re-
assistance to amputees. Enhanced certain how local amputee peer sup- sources could potentially improve
awareness of these resources is ex- port and education groups can thrive care worldwide.
pected to increase referrals from pro- and fulfill the important mission of Cooperative advocacy efforts are a
fessiona ls and use of their services. As education, advocacy, and empower- win-win situation. Health care and
consumer forums and advisory boards ment. National organizations such as disability coalitions have promoted
are beginning to commmucate con- the ACA and Wru: Amputations, with legislation for patient rights (Table 1),
sumer needs to agencies and organiza- central resource databases and fund- the Americans With Disabilities Act,
tions, this information m ust be shared ing, demonstrate the greatest poten- Veterans Administration Programs,
between professionals to further inte- tial for longevity. By developing pro- the Paralympic Games, the National

Center for Medical Rehabilitation and

Research, and the NLLIC. As federally TABLE 1 ACA Consumer Bil l of Rights and Responsibilities
funded priorities, these programs are All people who have experienced a disability have the right to:
increasing awareness, changing soci- Receive comprehensive, clear information about the medical, surgical, and
etal perceptions, and expanding op- rehabi litative aspects of care
portunities for dfaabled persons to be Participate fu lly in all decisions concerning their health and well-being and the
recognized as successful and contrib- development of a personalized rehabi litation plan
uting members of society. Continued Establish goals for optimal functioning, physical and emotional well-being, and
prevention of secondary conditions and complications
success depends on increased net-
Have access to peer support, funding information, and vocational/recreational
working and collaboration to provide resources
resources where needed. Improve- Be informed about appropriate and available prosthetic and orthotic services and
ments in communication, such as vir- devices, including new technologies
tual resources, could facil itate this Become knowledgeable consumers of safe, effective products and services
collaboration. Select from certified practitioners, and
Success in prosthetics and rehabili- Voice concerns about quality of care, billing practices, and services or products, and
tation depends on the ability of pro- seek redress if the highest quality standards are not met
fessionals to comm unicate, collabo-
rate, and keep the amputee consumer (Reproduced with permission from the Amputee Coalition of America, 1998.)
the focal point of care. Amputee con-
sumers must be integral to the devel-
opment and implementation of med-
data, disseminating findings, and in- 6. Schilder P (ed ): The Image and Appear-
ical, prosthetic, and allied health ance ofthe Human Body: Studies in the
science curricula. Multidisciplinary corporating results into standards for
Constructive Energies of the Psyche. New
professions that involve engineering, quality that are valid for rehabilita-
York, NY, International Unive rsities
art, and science must have a common tion in a variety of cultmes. Press, 1950.
language and focus. That focus is the 7. LaFleur JF, Novotny MP: Study of hu-
patient/consumer. Practitioners who Additional Resources man figure drawings by amputee chil-
understand practice management and dren and verbalization of their general
use a staff of reimbursement experts The ACA provides gift certificates for adjustment, in Krampitz SD, Pavlovich
can fail to maintain focus on the am- free publications and membership to N (eds): Readings for Nursing Research.
putee consumer. Without consider- new amputees. The ACA has a toll- St Louis, MO, CV Mosby, 1981,
ation for the holistic needs of the am- free number (1-888-AMP-KNOW) pp 259-266.
putee, prosthetic devices can become that makes it easy to obtain answers 8. Samarel N, Fawcett J, Krippendorf K,
expensive engineering feats that may et al: Women's perceptions of group
from a wide variety of resotuces listed
support and adaptation to breast can-
or may not adch-ess the specific needs through the NLLIC databases. cer. JAdv Nurs 1998;28: 1259-1268.
of the user. Curricula that address in-
9. Scholten C, Weinlander G, Krainer M,
terdisciplinary team communication,
relationships between form and func- References Frischenscb.lager 0, Zielinski CC: Dif-
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768 Section TV: Management Issues
Useful Websites
Amputee Coalition of America: Limbless Association UK:
www.amputee-coalition.org http://www.limbless-association.org
Center for International Rehabilitation: National Center on Physical Activity and Disability:
http://www.cirnetwork.org http://www.ncpad.org
Center for International Rehabilitation, Research, O&P Digital Technologies sponsored site for
Information, and Exchange: resources for orthotics and prosthetics information:
http://www.cirrie.buffalo .edu http://www.oandp.com
Disabled Sports USA: Rehabilitation International:
http://www.dsusa.org http://www.rehab-international.org
Landmine Survivors Network: War Amputations of Canada:
http://www.landminesurvivors.org http://www.waramps.ca
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20. Cammack S: Integration of pediatric
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16. Legro MW, Reiber G, delAguila M, et
al: Issues of importance reported by port systems in adolescent cancer am- JJ Jr (eds): Stress and Well-Being at
persons with lower limb amputations putees. Cancer l 985;56:965-971. Work: Assessments and Interventions for
and prostheses. J Rehabil Res Dev 1999; 23. Chalmers KI, Kristjanson LJ, Wood- Occupational Mental Health. Washi ng-
36:155-163. gate R, et al: Perceptions of the role of ton, DC, American Psychological As-
17. Geiger AM, Mullen ES, Sloman PA, the school in providing information sociation, 1992, pp 3-13.
Edgerton BW, Petitti DB: Evaluation and support to adolescent children of 28. Michael JW, Bowker JH: Prosthetics/
of a breast cancer patient information women with breast cancer. JAdv Nurs Orthotics Research for t he Twenty-
and s upport program. Eff Clin Pract 2000;3 l: 1430-1438. First Century: Summary 1992 confer-
2000;3:157-165. 24. Gray J: Men Are From Mars, Women Are ence proceedings. J Prosthet Orthot
18. Fitzgerald DM: Peer visitation for the From Venus. New York, :t\TY, Harper 1994;6:100- 107.
preoperative amputee patient. J Vase Collins, 1992.
Nurs 2000; 18:41-44.

Amputee Support Groups

From the Amputee Coalition of America
Paddy Rossbach, RN
Patricia Isenberg, MS
A support group can play an impor- community center, hospital, or inde- support group information added to
tant role in the recovery process for pendent living center. To establish the ACA database.
both recent and experienced ampu- the integrity of the support group, it Why: To determine the type of
tees. The following factors appear to should not be affiliated with a pros- meetings that will best meet the
be integral to successful psychoso- thetic facility or rehabilitation cen- needs of your grou p, ask potential
cial adjustment to limb loss: (l) a ter. This does not preclude receiving members. Do they want an open
strong support network of family space or supplies from such a grou p, discussion group with a facilitator,
and/or friends; (2) social support but the support group cannot be social gatherings, or formal pro-
from outside the family/friend net- seen as endorsing one practitioner grams followed by discussion?
work, such as from a peer visitor or facility over another. The ACA has found that groups
and support group members; and When: Decide on a regttlar meet- with the most longevity share the
(3) successful use of stress manage- ing time and date that accommo- following characteristics:
ment and coping strategies. dates most potential group mem- • Meet on a regular basis in a cen-
Support groups can be an invalu- bers. Support groups typically meet tral location
able resource for the new amputee, a monthly for 1 to 2 hours. • Offer a peer visitor program
place to observe others who are suc- Who: Will your group focus on • Have programs that are appro-
cessfully coping with limb loss and the needs of new amputees, or will it priate for a wide range of ages
learn new coping strategies. The focus more on experienced ampu- or clearly focus on one age
group can provide the opportunity tees? Will you include family mem- group
to discuss or practice coping tech- bers or caregivers? A1:e all ages wel- • Offer both structured programs
niques in a supportive atmosphere. come? Recruiting members will be a and social events for members
Anyone interested in starting and challenge, so be creative. Develop • Formalize the group's structure
maintaining a support group shou1d flyers to post in prosthetists' offices, so that responsibilities are di-
first answer the four "W" questions: hospitals, and rehabilitation centers. vided among a group of people.
Where? When? Who? and Why? Write an articlefor the local newspa-
Where: Look for a free space in per. Contact the Amputee Coalition
the community such as a church of America (ACA) to have your

770 Section IV: Managemen t Issues
The Peer Visitor

From the Amputee Coalition of America
Paddy Rossbach, RN
Patricia Isenberg, MS
One of the most significant inter- peer visit was a chance to talk about deal of information, including the
ventions an individual facing an am- confusion, pain, and feelings. In- process of surviving to thriving, how
putation can have is a meeting with stead, they got yet another lecture to deal with grief, an understanding
a trained peer visitor. A peer visitor telling them what to do. Feelings of of cultural differences, when an in-
is someone who has experienced an being overwhelmed and helpless dividual's needs are beyond the ca-
amputation, is living a full and pro- were made worse, not better. pability of the peer visitor and
ductive life, and has completed a A peer visitor should not try to should be referred to a health care
training program preparing him or think or act for the new amputee, as provider, how to conduct a visit in a
her to visit another individual and this fosters dependence and is con- variety of settings including by
his or her family facing a similar ex- sidered "solicitous" behavior. In psy- phone, and most importantly how
perience. chology literature, solicitous behav- to communicate. The course stresses
Good peer visitors are sensitive ior is defined as behavior that the different types of listening and
listeners who are trained in commu- appears positive but really under- the importance of each, and it
nication skills. They can facilitate mines adaptive functioning. There is teaches skills to encourage dialogue.
the new amputee's own recovery some evidence that solicitous behav- In addition, subjects or actions that
and self-exploration so that they can ior correlates with depression after should be avoided during a visit are
make good decisions for themselves. limb loss. covered in great detail.
Just being present tells the new am- Peer visitors are everyday people Each course participant is evalu-
putee, "I've been where you are and who typically are not professional ated for knowledge, through pre-
I know you can find ways to make counselors or therapists, and their and posttesting, and suitability,
your life complete again." Peer visits, purpose is not to give advice or through role playing and interaction
if done well, are shining moments. solve problems. Rather, they serve as during the session, before being cer-
An untrained peer visitor, on the role models, offer emotional sup- tified by the ACA. Names of certi-
other hand, can do more harm than port, and provide information about fied peer visitors are added to the
good. Inexperienced peer visitors resources available locally and na- National Peer Network database. Re-
can mistakenly believe they are there tionally. quests for a peer visitor are matched
to tell the new amputee, "Here's The Amputee Coalition of Amer- as closely as possible by several fac-
what you need to do." They may ica (ACA), the leading national non- tors, including age, sex, and type of
leave the meeting with the feeling profit consumer organization for the amputation. Personal visits are pre-
that everything went well. Unfortu- more than 1.2 million individuals ferred . When these are impossible,
nately, what they don't see is that living in the United States with the phone visits can be conducted. The
the new amputee may actually loss or absence of a limb, trains ACA evaluates the efficacy of the
feel worse, having been over- and certifies peer visitors. The ACA program periodically by asking vis-
whelmed with information. What runs full-day seminars providing ited individuals to fill out an evalua-
the person actually wanted from a prospective peer visitors with a great tion form.

Pediatrics
The Limb-Deficient Child
John R. Fisk, MD
Introduction
Much of the Atlas deals with prosthet- Epidemiology of 17.8% of newborns with limb defi-
ics, but the limb-deficient child needs ciencies.
much more than replacement limbs.
Congenital Deficiencies In a study based on findings of the
Even the surgeon must follow a differ- Congenital limb defects occur at an Active Malformations Surveillance
ent set of rules when working with approximate rate of 0.3 to 1.0 per Program and Brigham and Women's
children. The child missing all or part 1,000 live births. Because the United Hospital in Boston, McGuirk and as-
of one or more limbs is a growing, de- States does not have a formal and sociates4 estimated a prevalence of
veloping, and learning individual. complete registry of birth defects, the 0.69 per 1,000 live births for all types
Equally important, limb-deficient number and types of limb deficien- of limb deficiency. They reported that
children have parents and siblings cies are not precisely known. Using limb reduction defects are much
who are learning along with them. hospital discharge information ob- more common in the arms alone
Thus, those who work with limb- tained from national surveys designed (70%) than in the legs alone (18%) or
deficient children must consider to sample 20% of the community, in both arms and legs (12%).
many different factors beyond those nonfederal, and short-term hospitals Finally, the National Birth Defects
involved with treating adults. in the United States, Dillingham and Prevention Study initial report by
The child is not just a small adult. associates 1 have estimated that be- Yoon and associates 5 discusses the
In addition to the obvious differences tween 1988 and 1996, the incidence of largest and broadest collaborative ef-
brought about by growth, children re- congenital limb deficiencies has re- fort to identify infants with major
act differently to disabilities than do mained fairly constant at approxi- birth defects in the United States and
adults. The two major categories of mately 26 per 100,000 (0.26 per to evaluate genetic and environmental
pediatric patients with limb deficien- 1,000) live births. The authors ac- factors associated with the occurrence
cies are those with congenital deficien- knowledge that this rate is about one of birth defects. As of December
cies and those with acquired deficien- half of that reported by Froster2 for
2000, 7,470 affected subjects and
cies (ie, those who underwent British Columbia and Kallen and as-
3,821 control subjects had been en-
amputations). The child with a con- sociates3 for Sweden. Dillingham and
rolled. The data indicate tl1at limb de-
genital limb deficiency has no sense of associates 1 detail neither the specific
ficiency accounts for only 6% (452 of
loss and nothing new to adjust to. Any types of limb deficiencies nor possible
7,470) of all the various types of birth
prosthesis is seen as an aid, not a re- etiologies, but they do report that
defects when all anatomic systems are
placement, so if it does not truly aid 58.5% of all limb deficiencies in
included.
the child, tl1e child will reject it. In newborns involve the upper limb.
contrast, those who lose a limb be- Among those, longitudinal hand de-
cause of trauma or disease experience fic iencies are the most frequent, ac- Etiology of Congenital
a profound sense of loss and undergo a counting for 46.4% of upper limb
abnormalities. Longitudinal toe re-
Deficiencies
period of readjustment unless the am-
putation is performed when they are ductions were the most common After the initial shock, when sadness
very young. How well these children lower limb deficiencies found in sets in, the ever-present question of
manage tlus change greatly affects newborns. Overall, multiple congeni- "Why did this happen?" is on the
their acceptance of prosthetic limbs. tal limb deficiencies were identified in minds of every relative of an infant

774 Section V: Pediatrics
with limb deficiency. Although a bet- view, and therefore any genetic abnor- might reduce the risk of transverse
ter understanding of the etiology of mality is assumed to be passed down limb deficiencies.
certain limb deficiencies has been from one or both parents. ln limb de-
gained in recent decades, in most ficiencies, however, the genetic defect
cases the precise cause of the defect often happens spontaneously, called a
Response to Limb
remains unknown. point mutation. With a point muta- Deficiency
In general, the causative events are tion, neither parent has, and therefore Response to limb deficiency in chil-
categorized as genetic, vascular, am- does not pass along, the genetic ab- dren differs depending on whether
niotic, teratologic, and unknown, normality. This cru1 be trne even the loss is congenital or acquired.
with the unknown category being the when the defect is known to have a Children with congenital deficiencies
largest. Unfortunately, being told the future hereditary pattern, such as an will try to do whatever other children
cause of their chi ld's difference is w1- autosomal dominant or autosomal re- do, and we find that the only limita-
known is often just as frustrating for cessive pattern. tions these children experience are
parents and families as if a known In these situations, many famil ies those placed on them by adults. Left
cause had been found. Brent6 esti- wonder if a specific factor, such as ex-
mated in 1985 that 60% to 70% of all to their own devices, they are very
posure to certain chemicals, was re- adaptable. Amputees, on the other
congenitaJ limb deficiencies were sponsible for the event. Limb devel-
of unknown etiology. He found that hand, want to be the same as they
opment begins in the 4th week of were before the amputation. They
environmental causes were identified
gestation and is nearly complete by mourn the loss of the limb and are
in 10% of malformations, maternal
the 8th week. If an outside agent is in- angry and resentful. Their motivation
infections in 3%, maternal disease
volved in transforming a specific to use the deficient limb will . be
in 4%, uterine constraint in 2%,
gene, therefore, the exposure would greatly influenced by their ability to
and exposure of the fetus to recog-
have to occur within 8 weeks after resolve this inner turmoil.
nized drugs, chemicals, irradiation,
conception, a time when most women ,Nbether of congenital or acquired
or hyperthermia in 1%. Brent also
do not know that they are pregnant. etiology, the child's limb deficiency is
surmised that 5% of maJformations
In most cases it is likely that no out- a great somce of guilt for parents and
have a cytogenetic origin and that
side agent is to blame and that the ge- other relatives. They will proceed
about 15% are due to a single gene
m utation. netic mutation simply happened for through the stages of the universal
In 2001, McGufrk and associates 4 no reason we can identify with our grief process that Ki.ibler-Ross8 out-
estimated that 32% of congenital limb current state of knowledge. lined . Initially they will experience
deficiencies have no known cause and Agents responsible for birth de- shock, then denial and anger. Parents
that 30% are of genetic origin. They fects may either have a direct impact may approach their grief with bar-
broke down the latter into known he- on the tissue of the developing limb gaining, hoping to improve circum-
reditary disorders (15%), chromo- or induce a genetic abnormality that stances. They will also experience
somal disorders (6%), specific mal- leads to the defect. Several toxins, disappointment because their dis-
forma tion syndromes (5%), ru1d medications, and even vitamins a.re abled child does not match their
familial patterns (4%). They believed known to affect limb development at dreams. In time, with resolution and
that 4% of congenital limb deficien- early or later stages, the most notable acceptance, they will develop more
cies were related to a teratogenic being the medication known as thali- realistic expectations so that the child
agent and 34% were of vascular ori- domide. This medication was pre- will receive needed support and nur-
gin. Although the possibility of iden- scribed between 1959 and 1962 to turing. Health care professionals in-
tifying genetic abnormalities has in- help relieve the n ausea that is often volved with families working through
creased, identification does not always associated with early pregnancy, but these stages must learn to recognize
reveal the reason for the genetic ab- its inhibitory effect on angiogenesis the changes as they occur and be
normality in a particular child. resulted in many cases of phocomelia, prepared to alter their approach ac-
Rasmussen (unpublished data, a severe fail ure of development of the cordingly.
2000) reported that the causes of limbs. In very high doses, retinoic The Reverend Harold Wilke, born
more than 70% of birth defects are acid, or vitamin A, may also affect without arms and well-known for his
still unknown. Yoon and associates 5 normal limb development. Therefore, work with disabled persons, once said
wrote that "the specific genetic and the use of anti-acne treatmen ts con- that the most important action that
environmental factors involved in the taining high doses of retinoic acid are his parents took while he was growing
etiology of birth defects have, for the not recommended in the childbearing up was to decide to have another
most pru·t, eluded identification." period. Finally, Wang and associates 7 child. (Rev. Wilke, AnnuaJ Meeting
Genetic etiology is typically con- have reported that the periconceptual of the Association of Children's
sidered from the hereditary point of use of a multivitrunin supplement Prosthetic/Orthotic Clinics, 1989).

Chapter 61: The Limb-Deficient Child 775
That gesture showed him that tbey thinks of it. Children may also use emy of Sciences Prosthetics Research
loved him sufficiently for who he was prosthetic wearing practices to influ- and Development Committee. The
to risk having another child. Many of ence their relationship with their par- goal of the subcommittee was to raise
our patients' families, however, do not ents. For example, the prosthesis may the standards of prosthetic care for
reach this point of adjustment; they become the object of rejection when a children in the United States. Before
never completely resolve their grief. child is challenging parental author- this time, prosthetic components
The pediatric limb deficiency clinic ity, as in adolescence. were often not available in pediatric
team therefore must be concerned When limb-deficient children sizes. Prescriptions were withheld un-
with not only the patient but also the reach adolescence, they undergo the til the child started school and was
parents and other relatives. same intellectual and emotional then deemed to need a prosth esis.
As children with limb deficiencies changes as do other adolescents, but To begin the dissemination of in-
grow, they proceed through the same the limb deficiency makes this adjust- formation and the establishment of
stages of development as do all chil- ment much more difficu lt. Fre- clinical criteria, four major symposia
dren. In infancy, the accomplishment quently, adolescents reject their pros- were sponsored by the subcommittee
of normal motor milestones should thesis when they are confronted with to reflect the state of clinical expertise
be facilitated. A passive arm may offer a new group of peers. They don't during the 1960s. By 1970, the sub-
balance or be a prop for sitting and want to be "different." Once they are committee was charged to enlarge its
crawling. A prosthetic leg becomes accepted into a group, they resume sphere of activity to include children's
necessary when it is time to pull to use of the prosthesis for greater func- ortl1oses and mobility aids. Under the
stand. Developmentally oriented tion. This pattern can be seen some- guidance of Hector Kay, Assistant Ex-
physical and occupational therapists times with lower limb prostheses, but ecutive Director of the Committee for
are an invaluable part of the clinic it occurs much more often with upper Prosthetic Research and Develop-
team. limb prostheses. ment, tbe annual conferences were
Chil dren may continue to wear expan ded to include cooperating
lower limb prostheses because they clinic chiefs and their team members.
Adjustment to a are needed for ambulation, but they The Association of Children's
Prosthesis may go to extremes to hide them. Prosthetic/Orthotic Clinics has held
They may avoid swimming and wear an annual interdisciplinary confer-
Little sound evidence exists to explain clothes that mask the lin1b loss. These ence since 1972, and it is now the pri-
why some children adapt readily to a actions ind icate that the child has not mary forum in North America for the
p rosthesis and others reject anything yet accepted his or her body image. exchange of information on the limb-
that is placed on them. The difference Upper li mb prostheses tend to be re- deficient child. Members include not
between children's acceptance of up- jected outright when ch ildren experi- only individuals but also clinic teams,
per and-lower prosthetic lin1bs is well ence frustration with themselves. which stresses the importance of the
documented. Legs are required for team approach. As stated earlier, the
mobility, and once the child realizes limb-deficient child has multiple
this, the prosthesis rarely comes off. The Team Approach needs th at can only be addressed by a
Upper limb prostheses, on the other There is no question that the child is team approach .
hand, are not always accepted with not just a small adult and that a team
the same enthusiasm. approach is necessary to bring to-
The upper limb prosthesis does gether professionals with expertise in
Surgical Considerations
not replace a missing arm to the same addressing these concerns. In 1954, Children and adults heal differently,
degree as a lower limb prosthesis re- the need for an organized approach to and the skin of children, which is
places a leg. At best it is a tool, and if the management of juvenile amputees much more elastic than that of adults,
it does not enhance function, it will across the United States was discussed better tolerates the stretching neces-
be rejected. Several authors 2 ' 3 have at a meeting in Grand Rapids, Michi- sary to cover the end of the residual
studied the rejection of upper limb gan. Subsequently, Gerald F.S. Strong, limb. Skin grafts often mature suffi-
prostheses by children, but few con- Chairman of the Prosthetics Research ciently to tolerate direct weight bear-
clusions have been reached. Clearly, Board, appointed an interim commit- ing as well as the shear forces experi-
cosmesis and function are two major tee of 10 members to pursue the is- enced with socket wearing. The skin
concerns. A third factor, acceptance sue. Charles H. Frantz, MD, chaired can also develop a callus and benefit
by the parents of the child's disability, the first meeting at the University of from end bearing.
may be even more important. A par- Californ ia at Los Angeles in 1956. In The skeletally immature child
ent's acceptance of a cosmetic hand 1959, the group officially became the needs residua] limb growth for good
may have a far greater impact on Subcommittee on Child Prosthetic biomechanical function later. Growth
whether it is worn than what the child Programs within the National Acad- potential differs in the child with a

congenital deficiency and the chjld caps or plugs have been tried, but the and frequent socket rev1s10ns or re-
with an amputation. As a rule, the rel- results a1·e disappointing. 9•10 Mar- placements are necessary to accom-
ative length discrepancy experienced guardt11 in Germru1y suggests trans- modate this growth. Lambert 12 re-
in a congenjtal limb deficiency is planting a cartilaginous apophysis ported on children followed up at the
maintained. One must not, however, from the ilium or preserving an epiph- U1uversity of Illinois. He found they
leave this to chance. When planning ysis from the amputated portion of required a new lower limb prosthesis
the proper time for surgical interven- the limb. Usually there is a bursa! for- annually up to the age of 5 years, bi-
tion for a partial longitudinal defi- mation over the end of the bone, and annually from 5 to 12 years of age,
ciency of the femur (proximal femo- it can become exquisitely tender. Oc- and then once every 3 or 4 years until
ral focal deficiency), the proper use of casionally, skin breakdown occurs and 21 years of age. The need for frequent
serial scanograms is necessary. With the bone may protrude. Socket modi- and regular checkups by the clinic
the newer techniques of limb length- fication can delay revision, but once team is obvious.
ening and deformity corrections, the residual limb becomes sharply ta- The young and healthy tissue of a
proper documentation of growth po- pered, revision is necessary. This is of- child's residual limb is different from
tential is increasingly important. ten required repeatedly until skeletal that of the dysvascular tissue seen in
Residual limb length is of vital growth ceases. The residual limb many adt1lt amputees. Consequently,
concern for the child amputee, and length is not shortened overall be- alterations in fit are much better tol-
the use of disru·ticulation rather than cause the appositional growth has ef- erated in children. Nevertheless, the
transosseous ablation should be con- fectively added length to the bone. frequent necessary chru1ges present an
sidered to preserve as much length as One area where the option of pre- economic concern. To lengthen the
possible. For example, because 70% of serving length at all costs must be useful life of a prosthesis, materials
the growth of tl1e femm comes from carefully exercised is the posttrau- should be used that are easily length-
the rustal femoral physis, a long trans- ened and morufied, keeping in mind
matic partial foot amputation. For ex-
femoral amputation in a 2-year-old that the durability of children's pros-
ample, forefoot amputation caused by
results in a very short residual limb by theses is more important than their
lawnmower injury frequently results
the time the child becomes an adult. cosmesis. In that regard, soft covers,
in an infected residuum with plantar
A knee disarticulation will avoid tl1is although cosmetically desirable, are
scarring. It is advantageous to be able
problem. If a knee disarticulation is easily damaged and therefore are not
to walk barefoot without a prosthesis,
performed too close to the time of appropriate for the active child.
but making a functional partial foot
physeal closure, on the other hand, Above all, prostl1eses must facilitate
prosthesis, especially for a less-than-
the relative retardation of physeal function , and those that the child
optimal partial-foot amputation, is
growth on that side may not be suffi- must be careful of should be avoided.
technically challenging. Concerns re-
cient to avoid an overly long thigh. In the past, prosthetic prescription
lated to cosmesis, comfort, and func-
The solution to this dilemma is a dis- was postponed to the purported ideal
tion are very difficult to satisfy. Fre-
tal femoral epiphysiodesis. This pro- age at which a child could use an up-
quently, a Syme ru1kle disarticulation per or lower limb prosthesis, 13 but
vides end-bearing ambulation with
fitted with a prosthesis is the best op- now prostheses are prescribed at ages
shorter length, allows transfemoral
tion. This procedure leads to a cos- appropriate fo r specific terminal de-
knee components, and provides good
metically pleasing result in a child, in vices and feet. An effort has also been
sitting and stanrung cosmesis.
whom malleolar size rs not a problem. made to develop criteria for the pre-
Another reason to perform joint
Nevertheless, after investing much scription of costly myoelect ric limbs
disarticulations rather than diaphy-
time and emotional effort to preserve fo r very young children. Some clinics
seal transections in children whenever
length at all costs, the family is often are claiming that functional capabili-
possible is bony overgrowth, which
unwilling to consider revision surgery ties occur earlier than has been ob-
frequently follows metaphyseal- or
as an alternative to a very clumsy par- served in sound limbs. Controlled
diaphyseal-level amputations. This is
tial foot prosthesis. This problem studies are needed to evaluate the
the major complication of amputa-
should therefore be carefully consid- functional appropriateness of pre-
tion surgery in children, with an inci-
ered in the initial treatment of each scription ages. A recent collaborative
dence variously reported in tl1e range
partial foot amputation. study by a member of Shriners Hospi-
of 10% to 30%. Histologically, this is
appositional bone growtl1 of the re- tal Clinics has demonstrated that very
maining diaphysis and not growth Prosthetic young childi·en accept body-powered
from the remaining proximal physis. or electric-powered hands equally
Various techniques of handl ing the
Considerations well.1 4
bone and periosteum during runputa- Children have many unique pros- Lower limb componen ts are being
tion have failed to decrease the inci- thetic needs. As their minds and bod- proposed for children on the basis of
dence of this complication. Silastic ies grow, so do their residual limbs, successes with adu lts. It remains con-

Ch apter 6 1: The Limb-Deficient Child 777
troversial whether dynamic-response Summary (ed): Progress in Clinical and Biological

feet should be prescribed for children. Research. New York, NY, Alan R Liss,
Given the small body mass of the The needs of lim b-deficient children 1985, vol l 63A, pp 55-68.
child and the frequent need for new are indeed special. This section of the
7. Wang GW, Ga ugher WH, Stamp WG:
limbs because of growth, the efficacy Atlas brings together state-of-the art
Epiphyseal transplants in amputa-
of these components needs to be information to help aU the members tions. Clin Orthop 1978;350:285-288.
demonstrated. of the clinic team provide better care
8. Kubler-Ross E: 011 Death and Dying.
for these children.
The epidemiology of traumatic New York, NY, Macmillan Publishing,
amputations must be studied to learn 1969.
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fo r ch ildren. Lawnmowers, fa rm im- juvenile .imputee and its control by
l. Dillingham TR, Pezzin LE, MacKcnsie
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EJ: Limb amputation and limb defi-
ciency: Epidemiology and recent lnter-Clin Info Bull 1969;8:9-18.
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The lnternational Organi:cation for Med J 2002;95:875-883. rous, high-density polyethylene caps
2. Froster UG, Baird PA: Congenital in the prevention of appositional bone
Standardization ( ISO) has adopted a growth in the juvenile amputee: A pre-
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congenital limb deficiencies, as de- 1975; l 4:9-1 0.
s tudy. Am J Med Genet I 993;45:60-64.
scribed in chapter 62. No longer is it 11. Marquardt TE: Plastische Operatione
3. Kallen B, Rahmani TM, Winberg J:
necessary to learn a series of a ncient Infants with congenital limb reduction bei drohender Knochenburchspiesung
language roots to describe patients; registered in the Swedish Register of am kindlichen Oberarmstumpf: Eine
this new system, which uses only four Congenita l Malformations . Terato/ vorla ufige Milleilung. Z Orthop 1976;
basic terms-longitudinal, transverse, 1984;29: 73-85. 114:711-7 14.
partial, and total-has been accepted 4. McGuirk CK, Westgate MN, Holmes 12. Lambert C: Amputation surgery in the
by the International Society for Pros- LB: Limb deficiencies in newborn child. Orthop C/in North Am 1972;3:
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thetics and Or thotics and the Associa-
tion of Children's Prosthetic/Orthotic 5. Yoon PW, Rasmussen SA, Lynberg 13. MacDonnell JA: Age of fitting upper
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Prevention Study. Public Health Rep J Bone Joint Sttrg Am I 958;40:655-662.
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6. Brent RL: Prevention of physical and electric prostheses. J Assoc Child
mental congenital defects: Part A. The Prosthet Ortl10t Clin I 990;25:73-76.
scope of the problem, in Marois M

Terminology in Pediatric Limb
Deficiency
John R. Fisk, MD
Introduction
As the world continues to shrink and whether the term should be applied 1. The classification is restricted to
as international communication be- to a missing longitudinal or trans- skeletal deficiencies, where the
comes commonplace, an internation- verse segment. These types of issues majority of such cases are due
ally accepted system of terminology kept practitioners in Europe from ac- to a failure of formation of
that translates easily into different cepting the Frantz and O'Rahilly sys- parts.
languages is of paramotrnt impor- tem. In Germany, a different system 2. The deficiencies are described
tance. This was the goal of those who of nomenclature developed. By the on the basis of anatomic and ra-
set out to devise a system of nomen- early 1960s, terms such as peromelia, diologic characteristics only. No
clature for pediatric limb deficiencies. ectomelia, and dysmelia, which never attempt is made to classify in
Terminology for traumatic and have been used in the United States, terms of embryology, etiology,
surgical amputations in children fol- were recommended. 3•4 or epidemiology.
lows the traditional practices used to In 1970, a working group of the 3. Classically derived terms such
name adult amputations. The prob- as hemimelia and peromelia are
International Society for Prosthetics
lem arises with naming obvious fail- avoided because of their lack of
and Orthotics met in Dundee, Scot-
ures of formation . To call such defi- precision and the difficulty of
land, with the goal of deriving a sys-
ciencies congenital amputations, as translation into languages that
tem of terminology that would gain
had been done for many years, was are not related to Greek.
wider acceptance. This method was
recognized as inappropriate. In addi- Deficiencies are described as trans-
tion, some terms were based on Latin published in 19745 and with only mi-
verse or longitudinal. The former re-
and Greek stems t hat did not translate nor modification was ultimately ac-
semble an amputation residual limb
consistently in languages with differ- cepted by the International Organiza- in that the limb has developed nor-
ent origins. To remedy such problems, tion for Standardization (ISO) in mally to a particular level beyond
two different systems of nomencla- 1989. which no skeletal elements are
ture for congenital limb deficiencies present. All other cases, in which
were developed and came to be ISO Standard for tl1ere is a reduction or absence of an
widely used, one in the United States element or elements within the long
and one in Germany. Describing Limb axis of the limb, are dassified as lon-
In 1961, Frantz and O'Rahilly 1 Deficiencies Present gitudinal.
published a system that, with slight at Birth *
modifications by others, 2' 3 persists in M ethod of Descri ption
the vocabulary of many practitioners International Standard 8548-1:1989, 6 Transverse Deficiencies
in the United States. This system in- which addresses limb deficiencies With transverse deficiencies, the limb
troduced such terms as amelia, present at bir th, is summarized here. has developed normally to a particular
hemimelia, and phocomelia. These The standard has three constraints: level beyond which no skeletal ele-
terms also proved to have some draw-
backs, however. For example, the term
*Copies of standard 8548- 1: 1989 are available from the ISO Central Secretariat, 1, rue de
hemimelia means simply "half a Darembe, Case Postale 56, CH-1211 Geneva 20, Switzerland, http://www.iso.org, or from
limb." The question then arises as to any ISO member body.

780 Section V: Peruatrics
Upper Limb Lower Limb Scapula Clavicle

Total Total
Partial Partial
Shoulder Total Pelvis
Humerus
Total Total
Upper third Partial
Upper arm Thigh
Middle third
Lower third Radius Ulna
Total Total
Total Partial Partial
Upper third Leg
Forearm
Middle third Carpus
Lower third Total
Partial
Total
~
Carpal• Tarsal*
Partial Metacarpals
Metacarpal*
Total
Partial
I- Metatarsal*
Total
Partial
---- 1 2 3 4 5
I
Rays
Phalangeal*
(finger or thumb)
I Total
'. Partial
Phalangea1•
(toe)
Phalanges•
Total
Partial
'-"- 1 2 3 4 5
Figure 1 ISO designation of levels of transverse deficiencies of up- Figure 2 Description of longitudinal deficiencies of the upper
per and lower limbs. Note that the skeletal elements marked with limb using the ISO system. The asterisk indicates that the digits of
an asterisk are used as adjectives in describing transverse defi- the hand are sometimes referred to by name: 1 = thumb; 2 = in-
ciencies; for example, transverse carpal total deficiency. A total dex; 3 = middle; 4 = ring; 5 = little (or small). For the purpose of
absence of the shoulder or hemipelvis (and all distal elements) is this classification, such naming is deprecated because it is not
a transverse deficiency. If only a portion of t he shoulder or hemi- equally applicable to the foot.
pelvis is absent, the deficiency is of t he longitudinal type.
ments exist, although there may be
rugital buds. Such deficiencies are de-
scribed by naming the segment at
Ilium lschium Pubis
,- which the limb terminates and then
Total I - Total Total
Partial Partial Partial describing the level within the seg-
ment beyond which no skeletal ele-
Femur ments exist; for example, "transverse
Total deficiency, forearm, upper one t hird"
Partial (Figure 1). To describe deficiencies at
the phalangeal level, another descrip-
Tibia Fibula tor can be added to indicate the precise
Total Total
level of loss.
Partial Partial
longitudinal Deficiencies
Tarsus
Total With longitudinal deficiencies, there
Partial is a reduction or absence of an ele-
ment or elements within the long axis
Metatarsals
Total
/~
1 2 3 4 5
of the limb. There may be normal
skeletal elements distal to the affected
Partial bone or bones. The following proce-
Rays dure should be followed to describe
Phalanges* such a deficiency (Figures 2 and 3):
Total 1* 2 3 4 5 1. Name the bones affected, from
Partial proximal to distal, using the
name as a noun. Any bone not
named is present and of normal
Figure 3 Description of longitudinal deficiencies of the lower limb using the ISO system. form.
The asterisk indicates the great toe. or hallux.

Chapter 62: Terminology in Pediatric Limb Deficiency 781
Shoulder total
Upper arm total -
Upper arm middle -

third
-
Longftudlnat
Tillla toial
Tarsus partial
Forearm total Ray 1 total
Forearm upper
third -
-
Figure 4 The Day sys-
tem of recording defi-
Carpal total
ciencies. Transverse up-
Carpal partial ~ per limb deficiencies
Phalangeal total
"--
at various levels are
shown on the skele·
lli'·
a o,
•i '
ton and in Day's styl-
ized version on the Figure 5 An example of a longitudinal
right. deficiency is shown on the skeleton and
in Day's stylized representation on the
right, which shows not only the original
deficiency but also the treatment by knee
disarticulation .
2. State wheth er each affected The Day System 3. Henkel L, Willert HG: Dysmelia: A
bone is totally or partially ab- classification and a pattern of malfor-
sent. Day, a member of the original Kay mation in a group of congenital defect
3. In the case of partial deficien- committee of the International Soci- of the limbs. J Bone Joint Surg Br 1969;
cies, the approximate fraction ety for Prosthetics and Orthotics that 51 :399-414.
and the position of the absent developed the system described 4. Willert HG, Henkel HL: (eds): Klinik
above, devised a convenient method und Pathologie der Dysmelie: Die Fehl-
part may be stated.
4. For metacarpals, metatarsals, of recording deficiencies, which is bidimgen an den oberen Extremitiiten
shown in Figures 4 and 5. It is pre- bei der Thalidomid-Embryopathie.
and phalanges, the number of
sented here for the consideration of Springer-Verlag, Berling, NY, 1969.
the digit should be stated, with
the reader but should not be consid- 5. Kay HW: A proposed international
the number starting from the
ered a part of the ISO nomenclature terminology for the classification of
preaxia1, radial, or tibial side.
scheme. congenital limb deficiencies. Inter-Clin
5. The term ray may be used to re-
fer to a metacarpal or metatar- Info Bull 1974;13:1-16.
sal and its corresponding pha- References 6. International Organization for Stan-
langes. dardization: ISO 8548-1: Prosthetics
1. Frantz CH, O'Rahilly R: Congenital
For example, for a fibular hemimelia and orthotics-Limb deficiencies, Part
skeletal limb deficiencies. J Bone Joint 1: Method of describing limb deficien-
and partial foot, the new terminology Swg Am l 961;43:1202-1224.
cies present at birth. Geneva, Switzer-
would be "partial longitudinal defi- 2. Nomenclature for congenital skeletal land, International Organization for
ciency of the distal two thirds of the limb deficiencies: A revision of the Standardization, 1989:1-6.
fibula, complete deficiency of the Frantz and O'Rahilly classification.
fourth and fifth rays of the foot." Artif Limbs l 966;10:24-35.

Developmental Kinesiology
Introduction
Understanding how infants with out the innumerable problems of domi- on the internally rotated forearms in
limb deficiencies grow, develop, and nating his or her universe. 2 the «on-elbows posture." Although in-
move can help families and clinicians Contemporary evaluations of mo- fants now spend less time prone be-
determine approaches that are age ap- tor development, such as the Alberta cause of the current thinking that
propriate for children with limb defi- Infant Motor Scale,3 Bayley Scales of "back is best" when sleeping to avoid
ciencies. This chapter integrates Infant Development,4 Bruininks- sudden infant death syndrome, nor-
norms established for normal chil- Oseretsky Test of Motor Proficiency,5 mal infants learn to lift the head when
dren with the needs of children with Denver II,6 and the Pediatric Evalua- given the opportunity to be prone.
congenital deficiencies or acquired tion of Disability Inventory,7 and Six-month-old infants become profi-
amputations. A child is a growing, de- screening tools developed by Bly8 and cient at pivoting on the abdomen to
veloping person, and clinical inter- Illingworth 9 present a relatively simi- gaze at an interesting aspect of the en-
vention, both in terms of prostheses lar time frame for attainment of mo- vironment. Stability in the prone po-
and activities, should keep pace with tor milestones. The Functional Status sition enables independent arm and
and foster the emergence of the i nventory for Toddlers identifies de- leg movements to enhance explora-
young person's abilities. Although velopmental achievements by those tion of space. 16
growth and development begin at with upper or lower limb deficiency. 10 In the supine posi tion, the infa11t
conception, this chapter addresses Developmental targets can help guide keeps the upper and lower limbs
postnatal events. prosthetic prescriptions 11 • 12 and acutely flexed, with t he ankles acutely
Behavior is goal directed: the in- treatment goals 13' 14 (Figure 1). dorsiflexed. Shoulders, elbows, and
fant's curiosity leads to exploration of hands are also flexed. When the ex-
space visually, orally, aurally, and by aminer extends the infant's Limbs,
means of hand movements, rolling,
Body Alignment they rebound back to flexion, indicat-
crawling, creeping, and walking. Cog- Because of the position that had been ing flexor tone, reflecting both the
. nitive and psychosocial factors inter- assumed within the uterus and the elasticity of soft tissues and central
act with the infant's changing motor immaturity of the nervous system, the nervous system response. By the end
control, morphology, and physiology. newborn displays a flexed posture. 15 of tl1e first month, the newborn can
For those with limb deficiency, intel- When the newborn is placed prone, keep the head in the midline position.
lectual functioning appears to be un- the arms and legs tuck under the At 3 months of age, the infant lies in
related to the severity of the limb de- torso, forcing weight onto the upper extension, perhaps from increased
ficiency.1 As casual observation in any thorax. The head is turned to the side control of the limb and trunk exten-
playground or clinic confums, chil- to faci litate breathing. From this posi- sors as well as the effect of gravity. 15
dren display considerable intersubject tion, an infant develops the ability to By age 9 months, many infants dis-
and intrasubject variability. Motor lift the head against gravity and to ro- cover side lying, either as a posture
maturity appears to be influenced by tate it from side to side; these skills for playing or as a pause dming the
trial and error, autonomous central are accomplished, on average, within act of rolling from supine to prone.
pattern generators, and genetically the first month after birth. The infant With development, arm posture
predetermined central nervous sys- eventually lifts the head and upper changes from flexion to abduction
tem connections as the child solves trunk off the bed and comes to rest and extension when the head is in

Chin up; arms

and legs tucked Chest up (when
under torso prone, head and Reaches and misses;
1 mo upper trunk lifted); grasps; holds head
when supine, head in midline; lies in
in midline; brings extension; "ring sits";
1-2 mo hand to mouth rolls from supine to
3-4 mo side-lying
Sits on high chair;

pivots on abdomen
to gaze at object;
rolls; crawls; grasps
Sits with support; with three-jaw
stepping movements; chuck prehension
bimanual grasp 6-7mo
7-Smo
Stands with help;

sits unsupported;
pulls to kneel, pulls Stands holding
to stand furniture; cruises;
lies on side; Creeps;quadruped
purposefully releases position; goes from
8-9mo held object sitting to standing to
squatting; reaches to
9mo grasp
9-10 mo
Walks when
led
Pulls to stand by
furniture; grasps
crayon; fine pincer
grasp 11 mo
12 mo
Climbs stair
steps
Stands alone
Walks alone;
builds 2-cube
13 mo
tower
14mo
15 mo
Figure 1 Normal developmental milestones in infants and young children.

Chapter 63: Developmental Kinesiology 785
midline. When the head is turned to By age 9 months, the infant can tially, arm strength enables the
the right, the infant exhibits an asym- move from sitting to the all-fours po- youngster to pull to stand and to
metric tonic neck reflex posture. The sition, also known as the quadruped travel laterally along the support
right arm abducts and the right leg is position, supporting weight on the structure. The infant will shift weight
extended. The left arm is externally hands and knees. This is a good posi- from side to side, stamping one foot
rotated with the elbow flexed. tion for rocking, which provides and then the other. By age 10 montl1s,
Culturally related practices may af- proprioceptive cues to the arms and the infant can switch from sitting
fect the development of skills. In the 1.egs and stimulates the vestibular sys- to standing and back to squatting
United States, for example, infants are tem. A month or two later, the infant easily. 16
often placed in the prone position is proficient at sitting, capable of Skeletal changes contribute to pro-
during the day, whereas British in- moving from prone to sitting, from ficiency in standing. Femoral torsion
fants are more likely to be supine, and sitting to the quadruped position, or progresses from retroversion of about
skills in the preferred posture are from sitting to kneeling and then 35° at birth to about 11 ° as an adult,
likely to be more advanced. 16 standing. The child can sit in a high contributing to stability of the femo-
chair, resting the feet on the footrest. ral head in the acetabulum. The
"W" sitting, where the hips are inter- femoral-tibial axis changes from ini-
Sitting nally rotated and the hips and knees tial varus to valgus at age 2 to 3 years,
Infants have enough m uscle tone to are flexed, is often seen, although in- then straightens. Development of
support themselves when held in the fants with dislocated hips should be normal cervical lordosis may be re-
seated or stand ing position; however, discouraged from this posture. Some lated to neck extensor activity. Lim ita-
they are not able to sit or stand inde- infants prefer side sitting. 16 tion of hip extension reflects the
pendently because their propriocep- usual tightness of the iliopsoas during
tion and balance coordination are im- the neonatal period. Neonates (those
mature. Initially, when the neonate is Standing younger than 1 month) typically ex-
held in the sitting position, the head The first indication of standing is pri- hibit more external than internal ro-
oscillates from extension to flexion . A mary standing, in which the neonate tation of the hip. 19
3- month-old infant should be able to maintains standing when supported.
hold the head steady in midline. At Usually, the feet are hyperadducted
this age, infants are capable of "ring and may be plantar flexed. By age
Locomotion
sitting," propping themselves forward 4 months, primary standing abates Prenatal kicking, jumping, and re-
on the hands with the head held in and is replaced by "giving way," in sponding to stimuli give way to post-
midline, the hips abducted and exter- which the infant, when supported, natal stretching, kicking, and t hrust-
nally rotated, the knees flexed, and the caves into hip and knee tlexion. The ing of the arms and legs and rotation
soles touching. A few months later, standing posture (known as second- of the head and trunk. 20 By the fourth
the infant develops trunk control by ary standing) appears at about age 5 month , infants can roll from supine
briefly extending tl1e trunk, abducting months. The hips are abducted, the to side-lying, turning the head and
the shoulders, and flexing the elbows knees extended, and the feet a re pJan- trunk iJ1 "log rolli ng" fashion. Rolling
in a position called "high guard." 16 tigrade. When supported at the axil- on a regular basis is uncommon until
By age 8 months, many infants can lae, the infant will bounce up and age 6 to 7 months.
sit with support for 15 minutes or down. Early stepping movements are When supine, the infant lifts the
longer. At about the same time, the likely at 7 months, if the infant is sup- legs off the bed, bringing t he feet to-
baby learns protective extension, ported. These milestones are based on ward the hands and mouth . The in -
bringing tl1e hands to the supporting systematic observations of infants fant will tumble to the side, driven by
surface to prevent toppling forward. without limb deficiencies. Anecdotal the weight of the legs. Lifting the legs
Unsupported sitting is common by evidence suggests that infants with and extending and rotating the head
age 8 or 9 months. The seated posture lower limb deficiencies place the in - prepare the youngster to roll indepen-
allows the infant to reach for, grasp, tact leg closer to the midline to dently, which ordinarily occurs by age
bang, and mouth objects. The infant achieve this milestone. 7 or 8 months. Another early maneu-
gains skill at retrieving dropped toys By age 8 months, infants become ver is bridging, in which the infant
by shifting weight laterally. Most clin- proficient at pulling to kneel and then places the feet on the supporting sur-
ics fit prostheses before the infant is pulling to stand, supporting them- face with the hips and knees flexed
9 months old, but some recommend selves on the railings of the crib or and extends the trunk and hip, raising
th at the first upper limb prostl1esis be other stable structures. Self-supported the buttocks.
fitted when the infant begins sitting, 17 standing begins with flexed hips. By age 4 months, tlle infant en-
and a few offer a prosthesis to those Eventually the hip extensors contract gages in push-up behavior when in
younger than 3 months. 18 to produce a more stable stance. lni- the prone position, actively extending

the neck, trunk, and elbows to sup- siderable trunk waddling.22 Lateral Upper Limb Control
port weight on the hands. At age trunk bending also serves to advance
The newborn's grasp is reflexive with-
5 months, the push-up involves sup- the leg. The beginning walker is
out thumb activity. 15 Nevertheless,
port by the bands and knees. From somewhat top-heavy. The center of
within a few days of birth, the neo-
this posture, the infant can rock back gravity is closer to the xiphoid process
nate displays rudimentary eye-hand
and forth and side to side. 16 than to the sacrum, 15 necessitating
Crawling, maneuvering across the coordination when the trunk is sup-
holding the arms in "high guard" to ported and a moving target is pre-
floor with the hands while in the aid stability; consequently, carryu1g a sented.27 When supine, the 1-month-
prone position, involves pushing and toy is difficult at t his age. 23 Collapse old infant is apt to thrust the arms
pulling with the arms and legs while into a fall is common, but the child is
the abdomen grazes the surface. This upward, although the hands are usu-
proficient at resuming upright bal- ally fisted . Between age 2 and 3
skill is typical of a 6-month-old in- ance.4 The child takes short steps and
fant. months, many infants attempt to
Creeping, which is more sophisti-
keeps the trunk and limbs stiffly ex- bring a hand to the mouth.4 This de-
tended.21 velopment is sometimes regarded as
cated than crawling, is likely to appear
At 18 to 20 months of age, the indicating readiness for fitting a pas-
by 10 months of age. It requires the
child relinquishes high guarding and sive prosthesis. The device satisfies
infant to extend the trunk sufficiently
to keep the abdomen off the floor parental hand support and becomes parental needs for disguise of the
while being supported by the hands able to carry a toy while walking. Ini- limb deficiency, lengthens the defi-
and knees. The infant alternates tial contact matures to heel loading. cient limb so that it can later interact
movement of the right arm and left The base is more narrow, and the tod- with the intact limb, and assists the
leg, and then pulls forward with the dler can walk backward. 15 Stooping child's balance.28 Eye-hand control
left arm and right leg. Some infants and rising are skillful. becomes evident as the baby explores
discover plantigrade creeping, sup- During the second year of life, the its body while supine. Infants can fo-
porting weight on the palms and child discovers jun1ping off a low box, cus on an object held close to their
soles. Infants with unilateral upper running, ball kicking, and hopping.24 face and will turn the head to track
limb deficiency will perform a modi'- Children first rise from a chair by the item. Arm motion consists prima-
fied creeping maneuver, supporting lifting the leg, flexing the trunk for- rily of ballistic swipes and swats.24 By
themselves with the intact hand ward to enable sliding off the seat, age 3 to 4 mon tbs, the infant can turn
placed closed to the midline. and finally extending the hips and the head beyond midline to follow an
Another mode of locomotion is trunk. Skipping, which involves a step interesting target 20 and will grab an
hitching, sometimes called scooting. and a hop first on one foot and then object within reach. 27 At 4 months,
The seated infant leans on one hand the other, is not mastered until about the infant can grasp a rattle voluntar-
and externally rotates the ipsilateral ily and enjoys noisy toys, 15 rotating
age 6 years, although a yow1ger child
hip while elevating the opposite leg. and shaking them easily.24
can balance on one foot for several
The youngster then plants the oppo- The 5-month-old infant will have
seconds.25 At about the same age, d,e
site foot and pushes with that leg to relaxed the fisted posture and will ro-
youngster learns to kick, balancing on
slide the buttocks across the support tate the wrist to grab at a rattle or
one foot while transferring force to
surface. other small toy.4 The infant swipes at
the ball. The backswing appears first
The 9-month-old infant will prob- brightly colored dru1gling objects,
at the knee and later the hip. Follow-
ably cruise, shifting weight from one supporting hin1self or herself on the
th rough and forward trunk lean are
foot to the other while supporti11g hands and knees and shifting weight
more sophistjcated refinements. 16 to one hand while brushing o r grab-
himself or herself with the hands on
Rising from the floor is accom- bing the toy with the other hand.
crib railings or other furniture.
Weight is usually borne on the fore- plished first by com ing forward from When supported, the infant brings
feet. Goal-directed ambulation begins supine, flexing and rotating the trunk. the hands together. Transferring an
at approximately age 10 months.2 An- One hand reaches forward while the object from one hand to the other is
other prewalking skill is clambering other pushes against th e floor. The done haphazardly. The infant gains
up stairs and low chairs, which dem- legs are placed wide apart in a squat skill at visually pursuing an object
onstrates the ability to flex the hips and then to the upright stance. Rising without necessarily relying on tactile
independently and use the upper matures by age 7 years, 16 as does feedback; tl1is may indicate the desir-
limbs for assistance. gait. 26 Other ambulatory skills, such ability of prosthetic fitting before tac-
By age 1 year, the child steps diag- as cycling, skating, skiing, skateboru·d- tile dependence develops.2°
onally forward and sideward, which ing, dancing, jumping rope, and stilt At age 6 months, the infant still
4
widens tl1e walking base. 21 Indepen- walking, become part of the child's uses the whole hand to grasp a rod
dent walking is flat-footed with con- motor repertoire. but is increasingly able to grasp a

Chapter 63: Developmental Ki.nesiology 787
cube with three-jaw chuck prehension. Fine pincer grasp is expected at Prosthetic
sion.25 Unlike a younger infant, the age 1 year. 15
6-month-old can differentiate among At 15 months, most children can Considerations
reach, grasp, manipulation, and rebuild a two-cube tower, displaying ex- Infants younger than age 2 years have
lease. 24 Functional reaching involves cellent grasp, placement, and release been fitted with myoelectrically con-
the perceptual ability to interpret the as well as shoulder, elbow, and hand trolled prostheses.32' 33 For children
environment and then to orient the control. 25 A few months later, the with cable-controlled prostheses, ter-
hand toward the object.27 The infant child can turn pages in a book. By the minal device activation before age
has learned that the hands are exten- second birthday, a child can usually 2 years is appropriate because the
sions of oneself that facilitate bring- turn single pages, fold paper, copy a child is ready for bilateral grasp at this
ing objects to the midline. This is the ver tical line, 15 and eat from a spoon.24
age. Prosthetic use discourages the
rationale for fitting the 6-month-old The 3-yea r-old child can build a
child from developing compensatory
infant with a prosthesis.29 At this age, 10-cube tower, may be able to build a
unimanual motor control. 34
many babies can sit securely and bridge with blocks, and can copy a
Children with upper limb deficien-
transfer an object from one hand to circle and a cross, which involves lift-
the other,6 ' 15 ' 24 as well as hold an ob- ing the pencil from the paper at ap- cies have Jess strength, both on the
ject in one hand while the other bangs propriate intervals.25 A child of this deficient and on the opposite side,
it or picks at it.24 Rudimentary ele- age can also assist with hand washing than do normal ch ildren. 35 Therefore,
ments of handedness appear, 25 al- and drying and can trnbutton and un- these factors sh ould be considered in
though hand dominance is not fully zip clothing. 15 the design of prostheses and in the
established until age 2 years. 15 At age 4 years, the child can cut pa- development of functional standards.
Holding an object such as a spoon per with scissors, button and lace Myoelectric fitting and training at
in each hand and bringing them to the cloth ing, and pour from a pitcher. 3 years of age can proceed according
midline is typical by age 8 months, but Hair combing and tooth brushing are to Hermansson's 14-step skill index,
the infant cannot yet release one ob- expected of the 5-year-old. 15 from wearing the prosthesis and using
ject to pick up another. Grip and load A cookie crusher myoelectric pros- it as suppor t to cont rolled grip while
forces are coordinated sequentially. thesis powered by a miniature electric throwing overhead.36
Upon initial contact with the object, circuit has been fitted to infants as Children with severe limb deficien-
the infa nt lingers before initiati ng ad- young as 7 months. 30 A survey of 28 cies may develop alternate skiJls, such
equate grip force and tends to press on clinics revealed that more than one as prehensile grasping with the head
the object before reversing the direc- third of the patients were fitted before and shoulder or using the toes. 1 The
tion of force to lift it.27 The infant is age 9 months, when sitting is well es- hand function of young children with
not yet able to anticipate the object's tablished, although a few infants re- prostheses differs from that of chil-
weight so as to select an appropriate ceived prostheses before age 3 dren without deficiencies, and this
target force. Grasping a crayon is likely months. 18 In another series, the aver- should be considered when choosing
by 1 year of age.4 The 9-month-old in- age age of first myoelectric prosthesis developmentally appropriate pros-
fant starts to show true release, drop- fitting was 9 months, although half of
thetic designs. 37
ping one object to pick up another. the children received prostheses be-
The youngster can trap a moving ob- fore they were 6 months old.31
ject.27 Within the month, the child The ability to throw a ball develops Conclusions
uses the index finger for poi nting and d uring the first year of life,4 although
Growth and development of motor
can release objects without simply catching is unlikely before age 3 years.
skills proceed in an orderly sequence,
dropping them. 15 The youngster can Initially, the child will hold the arms
in front of the trunk. Later, the child
although the age at which infants and
now use both hands for goal-oriented
functions, such as opening a box with learns to follow th e trajectory of the children attain motor milestones var-
one hand and taking out its contents ball and to flex the arms to absorb the ies. Fitting infants and children with
with the other.24 force of impact. Subsequent skills in- equipmen t that exceeds their level of
Integration of sitting and arm use clude refinement in grasp pattern, maturity can negatively affect their
is particularly evident at age 10 force, and accuracy in catching and welfare, the parents' expectations and
months, when the infant can reach as throwing. 16 resources, and the efforts of the reha-
fa r forward as 10 inches with out top- The 2-year-old child usually can bilitation team. To support the child's
pl ing. At 11 months, the infant can use the hand to hold paper in place progress, age-appropriate prostheses
remove a cube from a cup, indicating while drawing. The 3-year-old child should be provided, and the child
improved eye-hand coordination as should be able to string beads and should be engaged in suitable activi-
well as a sense of depth and dimen- buttons. 4 ties.

cago, IL, Northwestern University,

References planning and selection of prostheses
for infants and young children with 1964.
I. French RW: Motor development and unilateral upper extremity limb defi- 26. Sutherland DH, Olshen R, Biden EN,
intellectual functioning: An explor- ciencies. Clin Orthop 1980;148:47- 54. Wyatt MP: The Development of Mature
atory study. Inter-Clin Info Bull 1973;
14. Patton JG: Developmental approach to Walking. London, England, MacKeith,
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2. Leonard CT: The neuxophysiology of training, in Meier RH, Atkins DJ (eds): 27. Bradley NS: Motor control: Develop-
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CA: Gait Analysis: Theory and Applica- Children With Upper Extremity Ampu- skill acquisition, in Campbell SK (ed):
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pp 46-64. phia, PA, WB Saunders, 1994,
15. Sobus KML, Karkos JB: Growth and
3. Piper MC, Pinnell LE, Darrah J, et al: development, in Gonzalez EG, Myers pp 39-78.
Construction and validat ion of the SJ, Edelstein JE, et al (eds): Downey & 28. Curran B, Hambrey R: The prosthetic
Alberta infant Motor Scale (AIMS). Darling's Physiological Basis of Rehabili- treatment of upper limb deficiency.
Can J Public Health 1992;83(suppl): tation Medicine, ed 3. Boston, MA, Prosthet Orthot Int 1991;15:82-87.
46-50. Butterworth-Heinemann, 2001, 29. DiCowden MA, Ballard A, Robinette
4. Aylward GP: Bayley Infant Neurodevel- pp547-560. H, Ortiz 0 : Benefit of early fitting and
opmental Screen Manual. San Antonio, 16. Goldberg C, Van Sant A. Normal mo- behavior modification training with a
TX, The Psychological Corporation, tor development, in Tecklin JS (ed): voluntary closing terminal device.
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5. Bruininks RH: Bruininks-Oseretsky Test delphia, PA, Lippincott Williams & 22:47-50.
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et al: The Denver II: A major revision 20:55- 56. M: Age-appropriateness of myoelec-
and restandardization of the DDST. 18. Sypniewski BL: Questionnaire survey tric prosthetic fitting. JAssoc Child
Pediatrics l 992;89:91 -97. concerning age at initial fitting. Inter- Prosthet Orthot Clin l 987;22:60-65.
7. Feldman AB, Haley SM, Coryell J: Clin Information Bul/ 1972;11:1-17. 32. Datta D, Ibbotson V: Powered pros-
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Inventory. Phys Ther 1990;70:602-610. 878-889. 33. Mifsud M,Al-Tennen I, SauterW, et
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First Year. Tucson, AZ, Therapy Skill the congen ital below-elbow amputee: hand for amputees under two year of
Builders, 1994. Axe we fitting them early enough? age. J Assoc Child Prosthet Ortl10t Clin
9. Illingworth RS: Basic Developmental Inter-Clin Info Bull 1976;15:7-lO. 1987;22:41 -46.
Screening 0-4 Years. Boston, MA, Black- 21. Stout JL: Gait: Development and anal- 34. Trefler E: Terminal device activation
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10. Pruitt SD, Seid M, Varni JW, Setoguchi Therapy for Children. Philadelphia, PA, Bull. 1970;9: 11-14.
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ceptual basis and initial application of 22. Gage JR: Gait Analysis in Cerebral Palsy. McNeal DR: Is body powered opera-
a fw1ctionaJ status outcome measure. London, England, MacKeith, 1991. tion of upper limb prostheses feasible
Arch Phys Med Rehabil 1999;80: 23. Higgins JR, Higgins S: The acquisition for young limb deficient ch ildren?
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Current trends and futuxe possibil i- tion. St. Louis, MO, Mosby, 1995, of children fitted with myoelectric
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11 :653-679. 24. Can1pbell SK: The child's development 88-92.
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developmental approach to treatment agement of the Juvenile Amputee. Ch i-

General Prosthetic Considerations
Introduction
The child with a congenital deficiency 15 years of age present with a congen- standard devices. One example is the
or acquired amputation presents a ital deficiency that can either be fitted equinus, or step-in, prosthesis that
paradox to most practitioners. With with a prosthesis or for which ampu- is fitted around an existing foot.
or without a prosthesis, children con- tation is the recommended treat- McCollo ugb and associates 5 de-
tinually accomplish things never ex- ment.1 These presentations include scribed four situations for using such
pected or even considered possible. deficiencies of the tibia or fibula; lon- nonstandard prostheses: ( 1) surgical
T heir balance and dexterity are amaz- gitudinal deficiency of the femur, par- conversion has been refused; (2) sur-
ing, as is their preference for activities tial (LDFP, formerly called proximal gical conversion has been delayed; (3)
that seem totally inconsistent with focal femoral deficiency, or PFFD); longitudinal deficiencies are being
limb absence, such as the double leg amputations resulting from amniotic observed; and (4) amputation is not
amputee who wants to be a running band constriction (Streeter's dyspla- an option because the child's upper
back or the transhumeral amputee sia); and various transverse or longi- limbs are involved, requiriJ1g the child
who becomes a guitarist. Even veteran tudinal absences of the upper and to use the feet to substitute fo r hand
pediatric clinicians remain fascinated lower limbs.2 (Many transverse ab- function .
sences are functio nal homologs of an Increasingly, ch ildren who might
when a girl who is missing both arms
uses her feet to put in her pierced ear- amputation. Because no surgical or in previously have required amputation
utero ablation ever occurred, such for cancer may now present with an
rings or sculpts or paints with her
conditions are not true amputations. endoprosthesis combined with an
toes. Children have a miraculous ca-
However, perhaps for lack of a better amputation, or they may have under-
pacity to adapt.
replacement, the term has stuck.) gone a rotationplasty.6 A modified ro-
The development of a child into an
Many children with congenital limb tation plasty, which rotates the foot
adult is full of surprising twists and
deficiencies will also demonstrate the 180°, is sometimes performed for
turns and unexpected outcomes. The
biomechanical challenges that Aitken children with LDFP to enable their
same growth and change also charac-
and Pellicore3 described as being ankle to function as a knee.
terize the practice of pediatric pros-
associated with their conditions-in- Regardless of the etiology of their
thetics. For those who provide pros-
adequate proximal musculature, un- limb deficiency, most children are
thetic care for children with li mb very active and participate in diverse
stable joints, malrotation, and limb-
deficiencies, a few general observa-
length differences. Multiple limb activities ranging from soccer, base-
tions and philosophies can be set
involvement occurs in perhaps 40% ball, dance, and swimming to playing
forth, combined with a short but fre- of cases.4 Trauma (eg, motor vehicle instruments or video games, march-
quently debated list of standardized ing in a band, cheerleading, golfmg,
accidents, burns, power tool or lawn-
practices. mower injuries) and cancer and other or rock climbing. Although many of
diseases accow1t for the remaining these activities can be performed with
Pediatric Prosthetic 30% of amputations in children. conventional prostheses, children and
In addition to designing "typical" adolescents often benefit from pros-
Considerations artificial limbs, prosthetists who work theses that are customized for specific
ln most pediatric prosthetic clinics, with children are often called upon to activities. Thus the pediatric prosthe-
about 70% of children younger than construct highly customized non- tist is faced not only with a challeng-

ing array of conditions and levels, but amputation is acquired at a later age, Flexible Sockets
also with meeting diverse needs that after the child has already been walk- Modern flexible thermoplastic sock-
are complicated by the dynamic, ever- ing, the child should be fitted as soon ets, generally contained within an
changing nature of pediatric clients. as he or she is physically able. outer open frame, enhance comfort
The fact that children continually The prosthetic prescription should and suspension and often provide im-
grow and change provides the pros- reflect the child's developmental proved growth adjustabil ity. The flex-
thetist and clinic team with some readiness. When fitting a toddler's ible material can be heated and
unique opportunities. On average, a fint transfemoral or knee disarticula- stretched, sanded down, or replaced
child may require a new prosthesis tion prosthesis, for example, many by a thinner socket. Pads may be
every year or two, creating the advan- clinics commonly incorporate a added between tl1e outer frame and
tage of an accelerated learning curve. locked knee for its simplicity or ex- socket and then removed later. In
Opportunities to observe and im- some cases, the material can also be
clude the knee joint altogether until
prove upon what was done previously made to "shrink." This not only en-
the child has learned to walk safely.
occur much more frequently than
Chjldren who require an arm pros- ables growth expansion but also helps
with adult prosthetic care. Thus the
thesis are usually considered ready for retain fit after edema reduction or
clinic team, patient, and family can
their first prosthesis when they start limb atrophy.
work together to tailor each consecu-
tive device to new and emerging to sit independently.9 Traditionally,
the first device has been a passive one, Gel liners
needs and interests, as well as benefit
with the goal of enabling the child to Liners constructed of thermoplastic
from the experience of what suc-
sit, crawl, and perform some biman- gels, urethane, or silicone often pro-
ceeded in the past.
ual activities such as holding a bottle vide a comfortable, protective inter-
Conversely, the ongoing changes in
or toy. Around 2 years of age, most face for adolescents and many chil-
children often require that the clinic
children are talking and also under- dren. Currently most liners are not
te;;im be patient enough to wait until
the child is physically, intellectually, stand cause and effect. This seems to commercially available in. size ranges
or emotionally ready for certain de- be the best time for them to be fitted that accommodate very small chil-
vices, interventions, or surgeries. For with and trained to use a terminal de- dren. When used to suspend a pros-
example, adequate space to accom- vice that can grasp. 10 Options at this t hesis by means of a locking pin or
modate a prosthetic knee or foot can stage include myoelectric hands or lanyard, such liners may also avoid
be achieved through an epiphysiode- body-powered hooks. Elbows and el- pressure over bony anatomy like the
sis; however, this must be done at the bow controls are generally considered femoral condyles and can thus be
appropriate age in order to avoid an only after the child has mastered use considered "growth friendly." The
extremity that is disadvantageously of the termi nal device. locking versions have the disadvan-
short. During the interim, shoe-lifts tage of being more difficult to modify
or alternative components or designs Strategies for Managing for distal bone overgrowth or to fit
will have to suffice. Similarly, certain Growth over sharp, tapered residual limbs.
prosthetic designs or components Although children will inevitably out- Slip Sockets
may be too heavy, complicated, frag- grow their devices, prosthetists, clinic
ile, or bulky for young children. Often Prosthetists sometimes include one or
teams, and therapists use numerous two inner layers inside the prosthetic
the ideal prosthetic prescription has
strategies to prolong the fit and func- socket, which can be peeled out later
to be delayed until the child has ma-
tion of pediatric prostheses. Most to accommodate growth. 12
tured enough for the application to
practitioners combine several strate-
be practical.
gies. Because children do not grow Appropriate Materials and
Initial Fitting Age uniformly in length and girth, no sin- Components
The child who needs a lower limb gle strategy will work every time. De- Children with amputations are gener-
prosthesis is generally considered scriptions of some of the most com- ally as active as their able-bodied
ready for fitting and early training mon strategies follow. u peers. Consequently, their prostheses
when be or she begins pulling to must be as durable as possible, while
Adjusting Prosthetic Socks not restricting activity with excess
stand. This developmental milestone,
which even chi ldren with high or bi- As children grow, tl1ey can wear fewer weight, bulk, or impractical compo-
lateral deficiencies will demonstrate, prosthetic socks or replace them with nents or materials. Designs, compo-
usually occms between age 9 and 16 thinner socks. Because many gel liners nents, and materials that can be
months. 7 ' 8 Pulling to stand seems to are produced in several thicknesses, switched out easily, that simplify
be the ideal time for prosthetic fitting the same principle can often be ap- lengthening, or that enable inter-
and early gait training to begin. If the plied to locking liners or gel liners. change to a larger or stronger compo-

Chapter 64: Gen eral Prosthetic Considerations 791
nent are preferred. Anything that is Education ers. 17 As with adults, children's emo-
toxic, easily lost or swallowed, or dif- Both the care providers and the child tions and self-acceptance can play a
ficult for a parent or child to apply should lea rn to apply, remove, and major role in how they perceive their
and use should be avoided. limb loss. the role of tl1ei r prosthesis,
care for the prosthesis. By watching
how the child walks, exam ining the and their willingness to try new activ-
Staging ities that may influence the prosthetic
condition of the residual limb, and
Some components are too large, re- prescription.
paying attention to any changes,
quire too much strength or range of In addition to their emotional ma-
the care providers should learn to
motion, or are inappropriately com- turity, children's life experiences, abil-
recognize when relief over bony
plicated for young children. A good ities, and interests are also constantly
prominences, sock reduction, length-
prescription plan should take into ac- and often dramatically evolving. This
ening of the prosthesis, or other
count the child's physical and intel- can present the clinician with addi-
adjustments are likely to be needed,
lectual readiness, the level and cause
and they should then contact the tional challenges. For example, a boy
of amputation, age of onset, and the
prosthetist. who has just received a new running
child's family and social dynamics. 13
prosthesis to achieve his goal of be-
In this context, the team often elects Follow-up comi11g a competitive spr inter may
to stage, or gradually increase, the
No design feature can replace ap- suddenly change his mind and decide
complexity of the device. This is
propriate follow-up. In general, to try out for the golf team instead.
partly based on development and
follow-up with the physician and Children frequently subject their
partly based on what components,
therapist should occur every 6 to 12 prostheses to activities and stresses
materials, or techniques can be prac-
months. Devices generally will require for which they were never intended.
tically applied. For these reasons, chil-
growth adjustments by a prosthetist Pediatric prosthetists often spend a
dren younger than 2 years of age with
three or four times per year. Most lot of follow-up time cleaning sand,
transfemoral amputations are often
pediatric limbs require replacement gravel, or water out of a child's pros-
fitted with a prosthesis that does not
every 12 to 18 months during peak thesis. Children with amputations
include a bending joint. Although this
practice may be growing less common gro"ving years, and perhaps every l to will want to swim, run, climb, play
with the introduction of improved 3 years during adolescence. 14 sports, and ride bicycles- just like
pediatric knees and therapy options, Most of these strategies are used in their peers. They will challenge the
the long-standing concept has been to combination. For example, a prosthe- clinic team to find creative ways to
enable the child to learn to walk with- tist might fit a transtibial amputee enable them to meet their full poten-
out the frustration of a knee joint that with a silicone locking liner along tial throughout a dynamic array of
may buckle at unwanted times. The with an overlying 5-ply prosthetic interests.
locked knee also reduces bulk and sock and modular components. Ini-
tially, as the child grows, sock thick- Bone Overgrowth
weight. Once the child has mastered
basic walking, the knee can be added ness is reduced. 15 Later, the gel liner Among children witl1 acquired trans-
to consecutive prostheses. Upper limb might be replaced with a thinner ver- diaphyseal amputations, periosteal
prostheses are also often staged in sion. Concurrently, relief to the socket overgrowth is the most common sur-
their complexity. For example, a child to accommodate growing bony prom- gical complication. Surgical methods
with a transhumeraJ deficiency may inences might become necessary, to reduce this tendency have met with
be fitted first with a passive hand, or along with angular alignment adjust- mixed results. Bone overgrowth re-
perhaps a friction elbow. The termi- ments beneath the socket adaptor, results in a sharp, spiked protuberance.
nal device may not be activated until placement of the pylon for a longer Through some advance planning, the
2 years of age, followed a year or so one, or interchange to a larger pros- prosthetist may be able to postpone
later by the addition of a functional thetic foot. the surgery.3 · 18 •19 However, over-
elbow, then finally, the elbow-lock growth will require surgical revision
control. As concepts and skills are Emotional Readiness once it becomes painful or erodes
gradually introduced and mastered, Children with congenital or acquired th rough the skin.
this incremental complexity should limb deficiencies are considered at For any pediatric amputation
reduce the child's (and parents') frus- risk for problems with psychological other than a disarticulation, the pros-
tration. Another parallel concept is to and social adjustment. 16 However, re- thetist should either include a distal
avoid "over-gadgeting" the child with ports vary widely on how successfully pad that can be replaced or modified
excessive, often unnecessary options. they cope. Success seems to be related when overgrowth occurs or have
Components and challenges should to the degree and quality of social some other related contingency plan.
be added only when the child is ready support these children receive from In most cases, a new pad, socket mod-
to handle and benefit from them. parents, siblings, peers, and teach- ifications, or a new prosthesis wi ll

provide only short-term relief until a children following their first prosthe- years; with pediatric patients, how-
surgical revision becomes necessary. sis or with children who have multi- ever, this goal is more short term in
ple limb involvement. Once the chjld nature. Although the device should be
Outgrowing a Prosthesis exhibits sigrnficant gait or postural reasonably durable, functional, ade-
Most growing children need a new deviations that were not present when quately cosmetic, and safe, the child
prosthesis every 12 to 24 months. the device was delivered, the prosthe- will outgrow it witlun a year or two.
Follow- up and growth adjustments tist can make only limited alignment Attention to cosmetic finishing will
should occur every 3 to 4 months. Of- alterations. At some point, the device vary according to individual prefer-
ten the need for a new prosthesis is may have to be disassembled and re- ences, but intricate, fragile, or highly
obvious-the child cannot fit into it aligned, or replaced completely. cosmetic covers are likely to fail with
at all or has lost it, or the prosthesis is When angular changes can no this very active population. More of-
beyond repair. These are good signs longer be addressed through adjust- ten, pediatric prosthetists are asked to
that the limb has been well used. At ments, the device should be replaced. manufacture tough, durable covers
other times, the choice between ongo- For example, a child with a Syme an- that will tolerate the child's high
ing repairs and adjustments or out- kle disarticulation for longitudinal activity level or to forgo tl1e cover
right replacement is less obvious. deficiency of the fibula may exhibit completely and provide devices that
Ft111ding constraints may also compli- increasing genu valgum. This could are brightly colored, uncovered, and
cate the process. To assist the team in resolve on its own, or it may eventu- look "sporty" or otherwise make a
making such decisions, a generalized ally reqwre a surgical medial growth statement.
list of indications for a new pediatric plate arrest (hemiepiphysiodesis). Re-
prosthesis follows. gardless, the changing alignment is
When the prosthesis reaches a The Lower Limbs
likely to require a new prosthesis.
point at which no further length or Partial Foot
growth adjustments can be made Fitting and Fabrication Children with congenital partial foot
without risk of injury to the patient, a Differences absences usually function quite well
new prosthesis is indicated. Repairs or without surgical intervention . Most
modifications may become so in- The pediatric prosthetist must often
do not develop contractures and have
volved that they are cost or time- evaluate alignment and fit primarily
few if any functional limitations.
prohibitive. Often this is a judgment through trial and error, by observa-
Their biggest challenge seems to be
call based on the frequency of adjust- tion, or by questioning the parents.
finding a shoe that fits, looks right,
ments, the patient's frustration level, Children, especially the very young,
and is comfortable. For this group,
or limitations of components or ma- may lack the verbal skill or the ab- soft slipper-style prostheses with pad-
terials. stract thought processes necessary to ded toe fillers are generally fitted . If
The socket may no longer corre- communicate their likes or dislikes additional support is required, a ther-
spond to the child's anatomy. For ex- about the prosthesis to the practi- moplastic arch support with a toe
ample, if the fibular head and tibial tioner. Older children and adolescents filler, or even something more rigid
tubercle have moved significantly out have grown more experienced with such as an ankle-foot orthosis (AFO)
of the reliefs originally built for them their devices, have greater language with a toe filler, may be provided.
in the socket, this is a sign that the skills, possess abstract thought pro- For children with acquired partial
child is outgrowing the prosthesis. If cesses, and can provide articulate foot amputations, my clinic prefers to
adjusting prosthetic socks or liner feedback to the prosthetist or thera- start out with a thermoplastic AFO-
thickness along with extensive modi- pist. This makes the alignment and style prosthesis that includes a pad-
fications cannot restore adequate fit, fitting process grow somewhat easier ded cosmetic toe. This is recom-
the prosthesis should be replaced. as the child matures. mended to enhance ankle stability,
Modern prosthetic components in- So the child can gain confidence protect the wound site, and avoid any
clude weight and activity limits, while alignment and fit are refined tendency for a contracture to develop.
torque settings, and time-based war- prior to the final fabrication of the Arguably, it may lengthen stride by
ranties. When the child's weight or device, pediatric prosthetists may al- providing a longer, stiffer toe section.
activity level exceeds the manufactm- low the child to begin gait training on If no tendency toward contracture is
er's specifications, the componen ts or an unfinished prototype prosthesis. evident, then less restrictive, more
the entire prosthesis should be re- This also lets parents observe how the flexible slipper-style systems are rec-
placed. child functions with the device out- ommended a year or so later.
The child's gait, posture, or joint side the hospital setting and often
aJjgnment may change to the extent improves the feedback they can pro- Fibular Deficiencies
that a new prosthesis is required. This vide to the prosthetist. A prosthesis When corrective procedures are un-
generally occurs more among young for an adult is intended to last many likely to succeed, a Syme procedure is

Chapter 64: General Prosthetic Considerations 793
often indicated for a complete or par- high incidence of knee instability, re- Knee Disarticulation
tially absen t fibula . The prosthetist current deformity, and repeated sur-
Knee disarticulation, rather than any
wi ll encounter a few fitting challenges gical revisions was reported. 20 Thus,
" through-the-bone" amputation, is
that are classically associated with this for complete absence of the tibia,
the preferred transfemoral level for
level. Although an ankle disarticula- knee disarticulation is now the proce-
children. This procedure minimizes
tion has been performed, the fibula is dure of choice.
wholly or partially absent, so the limb trauma, retains excellent hip muscle
The child with a knee disa rticula-
will not have the bulbous distal ap- balance and insertions, preserves both
tion, even if it is bilateral, can usually
pearance associated with the Syme femoral epiphyses, avoids osseous
be fitted prostheticalJy as soon as he
level. The child's heel pad and tibial overgrowth, and usually enables distal
or she is developmentally ready. By
malleolus may still be bulky and firm Load bearing. If tolerance of full distal
age 3 years, the child should be able to
enough to suspend the prosthesis, but weight bearing is maintained, knee
function well with an a rticulated
often some other form of suspension disarticulation is generaJJy considered
knee. Barring any other health prob-
such as a cuff, sleeve, or locking liner to be functionally superior to a trans-
lems, a high activity level should be
will be needed. Most of these limbs 21 femoral amputation. 22
expected. Many children with bilat-
ca n tolerate some loading of the distal Knee disa rticulation in children
eral knee disarticulations find that
soft tissues, but the heel pads have has most of the same disadvantages
they can learn to jog or run.
been known to migrate away, leaving associated with this level among
If the proximal tibia is present and
only a thin layer of skin to cover the adults, except that more options to
a functional quadriceps mechanism
tapered mal1eolus. To reduce long- correct the problems are available.
exists, a slightly different scenario
term stress on these tissues, a firm The bulbous distal end, for example,
takes place. In this case, the surgeon
distal pad and patellar tendon-bear- is not usually as notable in children
may be able to centralize the fibula
ing (PTB) or total surface-bearing who have had the amputation early.
and then perform an a nkle disarticu-
design should be emphasized. A The problem with matching knee
lation. Afterward, the child can be fit-
sharp, prominent tibial crest along centers and having fewer knee choices
ted with a Syme prosthesis. The knee
with anterior bowing of the tibia is can be circumvented by performing a
may need to be protected from injury
often present. To protect these a reas distal femora l epiphysiodesis at the
by using metal joints and a thigh cor-
from injury, a protective socket inter- appropriate age, thus eventually pro-
set until the fusion a nd knee joint are
face, special padding, or other appro- viding sufficient room for almost any
stable.
priate relief may be necessary. Fibular
Tra nstibial prostheses for ch ildren commercially available prosthetic
deficiency is often associated with a
should generally include distal pads knee. Even with these problems, sev-
length discrepancy. This can actually
that can be adjusted for longitudinal eral prosthetic socket designs have
be helpful because it allows more
growth o r terminal bone over- been developed to enable suspension
room for prosthetic ankles and feet,
growth. 11 As with ad ults, limb length, over the femoral condyles and to take
as well as distal pads and shuttle locks
skin condition, strength, and joint advantage of the long lever arm and
if indicated. Genu valgum is another
stability should dictate socket design, distal load tolerance of this level.
common problem. Medial placement
component selection, and alignment. A knee disarticulation usual1y re-
of the prosthetic foot may accommo-
Supracond ylar socket designs, which sults in femoral length nearly equal to
date this for a while, but if the valgum
becomes a cosmetic or fu nctional grip ove r bony anatomy, should be the opposite side. Standard single-axis
concern, a hemiepiphysiodesis or tib- used if indicated by Limb length or knees can add at least 5 cm to the
ial osteotomy may be required.4 stability. However, such systems are length of the prosthetic thigh. To
likely to need more frequent growth avoid this problem, a polycentric knee
Tibial Deficiencies modifications than do other less re- that is designed for the knee disartic-
Although it has now fallen out of strictive designs. Gel, urethane, or sil- ulation level should be used. Even the
vogue, a Brown procedure (fibular icone suspension sleeves and their best of these, however, may lengthen
centralization along with a Syme an - variants are arguably more adjustable the thigh by 25 to 30 mm. This dis-
kle disarticuJation) was often perfor growth over time because they do crepancy seems to be acceptable to
formed in the past for complete ab- not grip over bony anatomy. Al- most adults. 23 If an epiphysiodesis is
sence of the tibia. The intent was to though sleeves and suspension liners p~nn~ m ma~ more room for a
enable the fibu la to remodel and take are certainly appropriate for toddlers prosthetic knee, a minimum of 3 cm
on the role of the tibia so that the just learning to walk, prosthetists may of clearance should result, with some-
child could be fitted with a transtibial find that they get torn or wear out so where between 7 and 11 cm achieved
prosthesis. To provide mediolateral quickly during crawling that a waist by adulthood, so that virtually any
knee stability, metal joints and a thigh belt or so me other suspension is commercially available knee could be
corset were essential. Unfortunately, a preferable. used.

Transfemoral material and mates with a locking Manual locking Knees

Growth and development complicate mechanism built into the socket, thus Although many classes of knees can
the pr_osthetic managemen t of a locking the linlb onto the soft socket. be locked, this refers to a single-axis
child's transfemoral amputation. Tra- To remove the prosthesis, the child ei- knee with a lock. Among adults, these
ditional suction, the preferred ther pushes a release button or pulls are recommended only fo r patients
method of suspension for most adults the cord out of tl1e retaining lock. who need maximum stability. For
at this level, is usually not recom- Growth adjustments may be facili- children just learning to walk, how-
mended for children younger than 7 tated by the use of socks over the ever, manual locking knees are often
years of age. Certainly there are suc- liner. Although such systems are more appropriate, particularly for children
cessful exceptions; however, in gen- common at the transtibial level, they with bilateral amputations or defi-
eral, the child should have the hold great promise for earlier, more ciencies. The therapist, parents, or
strength, cognitive understanding, pa- successful suction fittings in children child can unlock such a knee for
tience, and maturity to apply a suc- with transfemoral amputations. 26 trnining purposes or to enable sitting
tion socket correctly-every time. If For young children, the most tra- or crawling. By 3 to 4 years of age,
the parents or other ca1·e providers ditional way to suspend a transfemo- most chjjdren wiili a single amputa-
are still helping the child get dressed, ral prostl1esis is wiili a Silesian belt. tion can learn to use an articulated
they are likely to find that applying a This fastens to the socket laterally knee without a lock. Those with high,
suction socket correctly is too frus- above the greater trnchanter, wraps weak, or bilateral absences may re-
trating and time-consuming. Such around the child's pelvis and opposite quire locking knees for many years, if
sockets usually require stable limb iliac crest, and then attaches with Vel- not indefinitely.
volume. Any air space distally can re- cro or a buckle on the proximal ante-
sult in negative pressures that may rior socket. The Total Elastic Suspen- Constant-Friction
cause circulatory congestion and ede- sion (TES) belt and other variations (Single-Axis) Knees
ma.24 Growth of the child's limb and made of neoprene, spandex, or nylon Constant-friction knees have a single
weight gain may result in frequent work in a similar fashion. The neo- axis of rotation and some mechanism
modifications or replacements of the prene is comfortable and gro . .vth- to apply friction at a constant rate.
suction socket in order to maintain a adjustable. Such belts can be used to The friction controls the knee during
comfortable fit. assist suction or some other form of swing phase and enables a smooth,
Although it is technically possible suspension, or they may be the sole controlled gait at a single, predeter-
to fit younger chi ldren with suction means of suspension. For extremely mined speed. Older children and ado-
sockets, it may create more problems short amputations, in the presence of lescents who are active and constantly
tha11 it solves until the child is at least rotational problems, weak hip abduc- change their walking speed will gener-
7 years old. 25 Thereafter, traditional tors, obesity, or hip pathology, a tra- ally prefer a hydraulic knee; however,
suction sockets should still be pre- d itional metal hip joint and pelvic only one or two choices are available
scribed judiciously until the child band and belt may be indicated; how- for children or smaller adolescents.
reaches adolescence. From the teen ever, this should be a last resort.
years on, suction sockets are generally Although far more prosthetic Stance-Control
tolerated and often preferred. As with knees are available for adults, a num- (Weight-Activated Friction)
adults, suction is not recommended ber of knee components engineered Knees
in the presence of deep, fissured scars, specifically for children have been Most stance-control knees are single-
frequen t changes in volume (as with introduced recently. Michael 27 has axis constant friction knees, but iliey
children undergoing dialysis or che- classified knee components into six also include a brake that is activated if
motherapy), extremely short residual categories, according to their func- the wearer's weight is applied during
limbs, or in the presence of upper tion: manual locking, constant- the first 20° of knee flexion . A few
limb deficiencies that would make fr iction (single-axis), stance control polycentric knees also provide a
donni11g of the socket burdensome. (weight-activated friction), polycen- stance-con trol feature. In addition to
Newer si licone, urethane, or other tric (four-bar), fluid-controlled, and the stability available thrnugh pros-
gel-like thermoplastic liners used in microprocessor-controlled knees. The t hetic alignment an d the patient's hip
conj unction with shuttle locks, lan- knees may differ greatly in appear- extensors, this weight-activated brake
yards, or even flexible sockets and ance, material, size, weight, or struc- provides an "anti-stum ble" mecha-
valves may be somewhat easier to t ural design, but their functional nism of sorts. Single-axis stance-
don. The liner is rolled over the resid- characteristics are very similar within control knees are generally recom-
ual limb and then the child "steps" each classification. Pediatric and ado- mended for new amputees, elderly, or
into the socket. Distally, a retaining lescent knees are now available in debilitated amputees, or patients with
pin or lanyaTd protrudes from the most of these classes. short or weak residual limbs. The pe-

diatric Total Knee (Ossur, Aliso Viejo, also provide resistance during stance, Longitudinal Deficiency
CA) is an example of a polycentric including features such as "lock" or of the Femur, Partial
knee (see below) with stance con- "free-swing." Hydraulic knees are rec-
Prosthetists are likely to see four or-
trol.28 The enhanced stability of such ommended for healthy, active adoles-
thopaedic methods of managing
knees is useful for fitting yow1ger cents. They would be ideal for yot111g LDFP. Each will require a different
children with any level of amputation children, but only one or two down-
prosthetic approach.
through or above the knee. sized units exist.
No Surgery
Polycentric (Four-Bar) Knees Microprocessor-Controlled
Sometimes no surgery is the best
Mechanisms in this class mimic the Knees
management option. This is particu-
rocking, gliding motion of the ana- Microprocessor-controlled knees have larly true for child ren with bilateral
tomic knee joint, either through been designed primarily for adults or LDFP or with bilateral upper limb de-
curved bearing surfaces or through a older adolescents; no system specifi- ficiencies occurring with LDFP. In
series of linkages. Polycentric knees cally designed for younger children is most instances, children with bilateral
bave a moving center of rotation. This presently available commercially. All LDFP should not have amputations.
generally enhances control against use a microprocessor and some kind Most can wall< independently; accord-
buckling and so these knees are more of feedback loop to control either a ingly, ablating their feet makes th~m
stable than single-axis knees. Several hydraulic or pneumatic knee. They very dependent on prostheses. Still,
variations have been designed specifi- have the benefit of far greater and they may benefit from a pair of exten-
cally for knee disarticulation levels or more instantaneous responsiveness to sion prostheses for use at school or
long amputations. These allow the situations the amputee may encottn- work. 29 Most children born with uni-
prosthetist to more closely match the ter during walking ru1d a m uch wider lateral LDFP can bear weight com-
patient's knee centers. Because the range of adjustability. However, tllese fortably on the affected side when
linkage "folds under" the amputee's knees share the disadvantages of they are not wearing their prosthesis,
thigh during flexion, some clinicians
greater expense, more stringent main- but tl1ey have to kneel or squat se-
consider polycentric knees more cos-
tenance schedules, a power source verely on the sound side in order to
metically pleasing dming sitting.
that must be recharged, and higher do this. These children are frequently
Only a few polycentric knees are
susceptibility to damage from water. fitted with equinus prostheses to
made for children younger than
10 years of age. Available feat ures compensate for leg-length discrepan-
Hip Disarticulation cies. The prosthesis raises them to the
such as weight-activated stance con-
The socket for a hip disarticulation correct height and includes a pros-
trol, spring-loaded extension assists,
prosthesis must generally wrap thetic foot below the plantar flexed
rubberized kneecaps to facilitate
around the child's pelvis. The hip anatomic foot. The child's anatomic
kneeling, and adjustable friction con-
joint is positioned anteriorly and the knee is usually included in the socket,
trols have made these popular choices
kJ1ee posterior to the body's midline and for cosmetic reasons, the foot is
in many pediatric clinics. Four-bar
knees are recommended for children so that the prosthetic joints are stable positioned in comfortable equinus. A
during midstance or when the patient waist belt or strap over the child's heel
and adolescents with knee disarticula-
tions or fo r any child with a transfem- is standing. Although soft cosmetic can suspend the prosthesis. Many can
oral or even a hip disarticulation who covers are less dmable for children in "self-s uspend" simply by dorsiflexing
needs extra knee stability. There are general, endoskeletal components are the foot actively against tlle socket
few if any contraindications to their generally recommended at this level. wall.
use in children. Such systems keep the prosthesis light Although equinus prostl1eses ru·e
ru1d also allow for long-term align- generally well accepted, the child's
Fluid-Controlled Knees ment changes. Toddlers or young weak, unstable hip and extremely
Fluid-controlled knees may be either children with a hip disarticulation high knee and foot create cosmetic
hydraulic or pneumatic and are avail- may be fitted with an articulated hip and functional challenges for the
able in both single-axis and polycen- only, along with a locked or nonartic- prosthetist. The limb may appear to
tric configurations. The fluid, which ulated knee. This facilitates early lengthen during swing phase and
may be liquid (oil), in the case of hy- walking and sitting. Perhaps by 4 or 5 shorten during stance phase. To coun-
draulic units, or gaseous (air), in the years of age, most children can learn teract this piston action of the unsta-
case of pneumatic units, responds to to use an ar ticulated knee effective- ble hip, the prosthetic socket often ex-
changes in walkiJ1g speed. Whether ly. 11 Because of their extra kJ1ee sta- tends to include the ischial tuberosity
the amputee walks slowly or speeds bility, polycentric knees-particularly and gluteal musculature. As children
up and nms, a smooth, controlled those with stance control- are often wearing equinus prostheses mature,
gait is the intended result. Some units advantageous for this level. they may find it difficult to sit in a car

or at a desk while wearing a prosthe- Rotationplasty of prostheses several inches shorter

sis. In such instances, the prosthetist Ideally, a rotationplasty turns the than the child's estimated normal
may choose to articulate the prosthe- child's foot around 180°, thus en- height may help the child learn to
sis by positioning a prosthetic knee abling the ankle to function as a knee balance, but this is often not neces-
joint below the child's foot, or by with a prosthesis. Rotationplasty has sary. Children with bilateral knee dis-
placing external metal knee joints on been used to treat LDFP as well as for articulations or higher amputations,
either side of the child's ankle. lin1b salvage following tumor resec- however, usually will benefit from
tion. For optimum function, the gradual progression in the height and
Syme Ankle Disarticulation child's ankle joint should be normal complexity of the prostheses.
The surgeon and family may decide and capable of an arc of motion o f at The young child with bilateral
on a Syme procedure alone. This least 60°.25 By maturity, the child's transfemoral amputations is usually
might be recommended as an alterna- ankle should be at the same level as first fitted with relatively short pros-
the opposite knee.33•34 theses without fw1ctional knee joints.
tive to lengthening, when the femur is
Bochmann7 has described the ideal Alignment generally reflects the
predicted to be 50% or greater than
prosthetic design following rotation- somewhat crouched appearance chil-
the sound side and the knee will func-
plasty. The child bears weight through dren exhibit when first walking: The
tion normally. A drawback to this ap-
the now anteriorly located sole of the hips are flexed and abducted, the
proach is that the thigh on the ampu-
foot, which is enclosed within a knees are flexed, and the ankles are
tated side will be visibly shorter.
socket. The socket is positioned in dorsiflexed. These prostheses gener-
When the child sits, the relatively long ally include prosthetic feet, but if the
prosthesis and short thigh are most equinus and provides extra space dis-
tally for growth of the toes. A soft amputations are extremely short or if
visible. Despite this cosmetic disad- fitting is complicated by developmen-
socket liner is recommended. To sta-
vantage, the child will be able to con- tal delays, tl1e prosthetist may forgo
bilize the ankle and protect against
trol the prosthesis with his or her an- feet in the interest of balance. Instead,
i11jury, single-axis joints extend from
atomic knee joint. Children who have some sort of crepe-lined stable soles
the socket and attach to a corset or
had this procedw·e generally walk well may be used as a base of support.
plastic thigh cuff. If necessary, ischial
as well as run and tolerate prosthetic (These have been traditionally re-
or gluteal support may be provided
fitting easily. As with LDFP in general, ferred to as "stubbies.") In either case,
through an extended socket brim. The
the abnormal hip and shorter, weaker relative shortening of the prostheses
prosthesis is usually suspended by a
hip abductors may produce a visible lowers the child's center of gravity.
heel strap or a waist belt. As with
Trendelenburg lurch. This provides for early successful
LDFP in general, the abnormal and
standing balance and helps the clinic
weak hip may produce a Trendelen-
Syme Ankle Disarticulation team evaluate prosthetic socket fit
burg lurch when the child walks.
With Knee Fusion with the child in a safe, comfortable,
Strength and remaining range of mo-
This combined approach is the most weight-bearing position. This stage is
tion of an appropriately rotated ankle
common surgical and prosthetic usually quite temporary, ranging from
will determine the degree of func-
management option recommended a few days to a few months. The short
tional knee control. Most children
for more severe cases of LDFP. A nonarticulated prostheses may be
and adolescents who have this proce-
Syme procedure is performed and the lengthened over time as the chjld be-
dme will be very active; therefore,
gins gait training.35
child 's knee is fused to form a single, dynamic-response feet and sports-
Deciding whether to fit shorter,
straight limb. The knee fusion gener- oriented components are recom-
nonarticulated prostheses o r to add
ally decreases the child's hip flexion mended.
knees right away requires experienced
contracture. 30•31 The limb is then fit-
Bilateral Lower Limb judgment. Children with longer am-
ted as a transfemoral amputation
putation levels (particularly knee dis-
with some distal weight-bearing capa- Deficiencies and articulations) and good upper limb
bility. Ischial or gluteal weight bearing Amputations strength usually progress quickly.
is provided to lessen pistoning of the When they are developmentally ready, They may be able to tolerate taller
unstable hip. In some cases, as with even children with bilateral leg am- prostheses with knees almost imme-
other Syme prostheses, the malleoli putations will attempt to pull to diately upon attempting to walk. In
and heel pad may be used to suspend stand. This is a good indicator that contrast, children with shorter ampu-
the device. Pads, expandable sockets, they are ready for their first prosthe- tation levels, or those who also have
and removable windows have all been ses. Fitting for bilateral trans tibial upper limb involvement, may require
used successfully, as have Silesian absences is not much different than years of experience before they are
belts and various elastic or neoprene for unilateral absence. Keeping the able to use longer prostheses with ar-
waist belts. 32 child's overall height on the first pair ticulated knees successfully. The tran-

Ch apter 64: General Prosthetic Considerations 797
sition to bending knees can be facili- cosmetic appearance of an upper years, so that the child learns to use
tated with options like manual limb prosthesis, whicb helps the child two muscle groups, as with most
locking knees, weight-activated fric- appear "like everyone else," may be adult myoelectric hands. A two-site
tion knees, polycentric knees that the true underlying motivation for system gives the child independent
provide greater stability, knee exten- seeking a prosthesis. control of both opening and closing
sion assists, walkers, crutches, canes, The clinic team will generally want of the hand. Children as young as
and, of course, prolonged physical to plan upper limb prosthetic inter- 3 years of age can learn to operate
therapy. vention around normal developmen- a hand with a two-site electrode
tal milestones. Most centers fit upper system. 37
limb prostheses when tlie child starts A variety of body-powered termi-
The Upper Limbs to gain sitting balance. This is usually nal devices are also available for
Managing a chi ld with a congenital between 3 and 7 montl1s of age, when young children. A passive hand is
upper limb deficiency differs signifi- children develop two-handed skills.36 usually fitted when the child begins to
cantly from managing an adult or ad- The first prosthesis is usually passive. sit, followed by an activated hook at
olescent whose limb deficiency is ac- Between 1 and 2 years of age, when around 2 years of age. Devices such as
quired tl1rough amputation. Children the child starts to speak, a functional tumbling mitts, ski pole attachments,
with congenital upper limb deficien- terminal device is fitted. Choices in- baseball glove attachments, and nu-
cies generally possess a remarkable clude body-powered hooks a11d hands merous other sports or tool adapta-
capacity for adapting to their situa- and myoelectric hands. tions are available or can be custom-
tion. The dexterity and sensitivity ized to tliread into a prosthetic wrist.
they exhibit with the residual limb is Transradial Deficiencies Such devices meet the child's needs
often quite amazing. Children with and Amputations for very specific activities such as
high bilateral deficiencies may prefer horseback riding, biking, or gymnas-
Regardless of the etiology, most tics. At other times, children and ado-
not to wear prostheses at all. Children
young children with transradial am- lescents may prefer a cosmetic pros-
with bilateral upper limb deficiencies,
putations will learn to use the elbow thesis. Peak desire for· such a device
for example, prefer to use their feet
effectively for prehensile activities. Al- seems to be when the child first starts
for functional activities. They may
though they can operate a prosthesis school, when the ch ild switches to a
learn to operate prostheses impres-
quite well, they will often have little new school, or during early adoles-
sively well, but they will usually revert
functional need for one. If they use a cence. There are few, if any, reliable
to foot use when allowed to do so.
prosthesis at all, it is generally for very predictors for which style of arm
Children born witl, a partial arm or
specific activities. The challenge for prosthesis a child will prefer or ulti-
hand will also function weJJ by adapt-
the clinic team is often sifting mately use as an adult. Clinics vary in
ing their remaining Umbs to their
through the array of choices to settle their approach. A common protocol is
needs. Sensory discrimination with
the residual limb is excellent. A pros- on something tl1e child will actually to fit children with passive prostheses
thesis, adapted tool, or sin1ple change use and benefit from. as they gain sitting balance, followed
to their environment (such as door Myoelectric hands are popular be- by prehensile training at· 2 years of
handles instead of knobs) may help cause of their good cosmetic appear- age. After tliat, prosthetic design and
them functionally or cosmetically. ance and the fact th at the device usu- use are based on the child's needs and
The prescription of a prostl1esis ally requires no harness. Grasping and i11terests.
should take into consideration the hooking functions are easily mas-
unique efficiencies these children tered. In the last 15 years, children Higher Levels
have already developed. If their cur- younger than 3 years of age often have A similar pattern exists for children
rent adaptations are not recognized, been provided with a myoelectric arm with transhumeral deficiencies. The
they may perceive a prostliesis as that is controlled through a single first prosthesis may include a passive
more of an imposition than a func- electrode positioned over just one elbow and passive hand. At around 2
tional aid. muscle site. This system has been re- years of age, either a myoelectric or
When appropriately designed and ferred to as a "cookie crusher." All the cable-operated hand or hook is
used, an upper limb prosthesis can be child has to do is contrnct the muscle added. Once the child has mastered
a helpful tool that a child may wear group below the electrode (preferably use of the terminal device, a fw1ction-
only intermittently for specific activi- an extensor in the forearm), and the ing elbow (either electric or body-
ties. This is in contrast to lower limb hand opens. As soon as the child re- powered) is added. The final skill to
prostheses, which childxen usually laxes, the hand will close. This enables be learned is usually locking and un-
quickly incorporate into their body even very young children to operate a locking of an elbow. Most children
images and tend to depend on daily myoelectric hand easily. The system should have the cognitive and physi-
for long periods of time. Often the should be converted within 1 or 2 cal ability to control all aspects of a

transhumeral prosthesis by 4 or 5 Summary pediatric prosthetic evaluation and

years of age. However, they may lack training, in Atkins D, Meier R (eds):
sufficient strength, range of motion , The growing, ever-changi11g nature of Comprehensive Management of the
and excursion to take full advantage children presents a dynamic challenge Upper-Limb Amputee. New York, NY,
of a body- powered system. Because of to prosthetists ru1d clinics treating Springer-Verlag, 1989, pp 137-149.
this, children and adolescents are of- children with limb deficiencies. Over 10. Shaperman J, Landsperger S, Setogu-
ten fitted with combination systems, the years, dillies have developed strat- chi Y: Early upper limb prosthesis fit-
egies for prescribing and fitting pedi- ting: When and what do we fit?
or hybrids, consisting of body-
atric prostheses. The keys to su ccess J Pros th et Orthot 2003;15:11-17.
powered and electronic components.
are listening carefully and frequen tly 11 . Cummings D, Kapp S: Lower-limb
Hyb rid systems maximize all available
to tl1e evolving needs of families and pediatric prosthetics: General consid-
control options and are especially
chiJdren and then remaining as flexi- erations and philosophy. J Prostliet
helpful when fitting higher amputa- Orthot 1992;4:203.
tion levels or children with bilateral ble and open to change as possible.
12. Gazely W, Ey M, Sampson W: Use of
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tion Surgery and Rehabilitation: The
cal Prosthetic, and Rehabilitation Prin- pp 108-127.
Toronto Experience. New York, NY,
ciples, ed 2. Rosemont, IL, American 30. King R, Marks T: Follow-up findings Churchill Livingstone, 1981.
Academy of O r thopaedic Surgeons, on the skeletal lever in the surgical
management of proximal femoral fo- 36. Hubbard S, Kurtz I, Heim W, Mont-
2002, pp 665-688. (Originally pub-
cal deficiency. Inter Clin Info Bull 1971; gomery G: Powered prosthetic inter-
11 : 1. vention in upper extremi ty deficiency,
25. Thompson G, Leimku ller J: Prosthetic in Herring J, Birch J (eds): The Child
management, in Kalamchi A (ed ): 3 1. King R: Providing a single skeletal le-
With a Limb Deficiency. Rosemont, IL,
Congenital Lower Limb Deficiencies. ver in proximal femoral focal defi-
ciency. Inter Clin Info Bull 1966;2:23. American Academy of Orthopaedic
New York, NY, Springer-Verlag, 1989,
Surgeons, 1997, pp 417-43 I.
pp 210-236. 32. Tablada C: A technique for fitting con-
ver ted proximal femora l focal defi- 37. Baron E, Clarke S, Solomon C: The
26. Schuch M: Transfemoral amputation:
ciencies. Artif Limbs 1971;15:27-45. two stage myoelectric hand for chil-
Prosthetic management, in Bowker
dren and young adults. Orthot Prosthet
JH, Michael JW (eds): Atlas of Limb 33. Krajbich I, Bochmann D: Van Nes
Prosthetics: Surgical, Prosthetic, and Rotation-plasty in tumor surgery, in 1983;37:11-12, 22-23.
Rehabilitation Principles, ed 2. Rose- Bowker JH, Michael JW (eds): Atlas of
. American Academy of Orthopaedic Surgeons

Psychological Issues in Pediatric
Limb Deficiency
Alice L. Kahle, PhD
Introduction
Approximately I million children and sis creates more stress for parents be- the child's psychological adjustment.
adolescents in the United States have a cause it triggers fear and uncertainty. Few studies, however, have compared
chronic illness or disability that neces- Others have argued that prenatal ruag- adjustment outcomes based on the
sitates ongoing, comprehensive medi- nosis allows parents to prepare them- origin of the limb deficiency or the
cal care. 1 Compared with other chil- selves and others for the arrival of a limb or limbs involved because re-
dren in this group and with peers child who will need specialized care. searchers often pool data from chil-
without physical disabilities, children One study examined this question dren with different types of limb loss
with limb deficiencies and am puta- specifically in parents of children born to achieve adequate sample sizes.
tions generally show good adjustment with a range of congenital anomalies. Nevertheless, researchers typically do
and coping. In fact, child and adoles- Researchers found that 1 year after the include some objective rating of de-
cent amputees have been described as child's birth, mothers who bad prena- gree of limb deficiency in their analy-
remarkably resistant to maladjust- tal information about thefr child's ses. As is often seen in children with
ment.2'3 Nevertheless, childhood limb condition reported significantly other chronic conditions,5 the rela-
deficiency, whether congenital or ac- higher parental burden and grief than tionship between characteristics of
quired, is emotionally significant. parents who lacked advance knowl- the deficiency, such as the nature and
Even uJ1der optimal circumstances, severity of limb loss, and psychologi-
edge of their child's anomaly.4 Gener-
coping with limb deficiency is w1- cal outcome is more complex and less
alizations from these data need to be
doubtedly challenging for the affected obvious than one might assume.
made cautiously because the sample of
child and fami ly. mothers who had prenatal informa-
This chapter focuses on the psycho-
Condition Severity
tion was very small (n = 8). Also, no
logical adjustment of children with Often, it is assumed that more severe
prospective studies have directly com-
limb deficiencies. In the first part of deficiencies will have a greater impact
pared the reactions of parents who
the chapter, the effects of experiences on psychosocial outcome. Yet, most
had p renatal information about theu·
and environment on the psychological clinicians have worked with children
child's limb deficiency with those of
adjustment of the child with a limb with significant impairments who
parents who learned of limb defi-
deficiency are discussed. In the second show exceptional emotional resilience
ciency at the time of their child's as well as with children with more
part of the chapter, practical tech-
bfrt11. Even so, given the proliferation minor impairments who adjust
niques for supporting the adjustment
of prenatal diagnostic techniques, the poorly. These anecdotal observations
in chjJdren with amputations and
findings point to the need to better mirror research findings in limb-
their families are presented.
understand how prenatal information deficient children and other child1·en
affects parental coping. with chronic conditions or disabili-
Prenatal Diagnosis ties.
What is the psychological impact of Degree and Type of Studies examining the relationship
having advance knowledge that a child between condition severity and psy-
Limb Deficiency chosocial functioning of these young-
will be born with a congenital anom-
aly such as a limb deficiency? Some The nature and extent of a child's sters and their families have produced
have speculated that prenatal diagno- limb deficiency certainly play a role in mixed results. Some researchers have

802 Section V: Pediat rics
found a direct relationship between depend on the etiology of the defi- and anger may disrupt adjustment as
condition severity and adjustment ciency, studies show otherwise. In one patients and family members deal
outcomes. For example, parents of in- of the few empirical studies to com- with the realization that the amputa-
fants with multiple congenital anom- pare children with different limb loss tion could have been avoided.
alies reported significantly more per- etiologies, adolescents with acquired Amputation entails not just a
sonal strain than parents whose child amputations were no different from physical loss but a multitude of po-
had an isolated anomaly. 4 In addition, those with congenital limb deficien- tential emotional losses as well. Am-
conditions with coexisting cognitive cies in terms of their depressive putation may force children to alter
or intellectual impairments are asso- symptoms, anxiety, or self-esteem. 7 aspirations, rethink vocational plans,
ciated with higher psychological mor- Children with a congenital limb or give up previously enjoyed hobbies
bidity than conditions that do not deficiency may have longer to prepare or recreational activities. Because
have these characteristics.5 for their limitations, which may facil- children with congenital limb defi-
When researchers examine patient itate patient and family adjustment. 13 ciency never experience life without a
groups within which there are fewer For patients with acquired amputa- disability, some authors have sug-
differences in condition severity, such tions, loss of fw1ction is usually gested that they may be less vulnera-
as children with limb deficiencies, di- abrupt. Patients may experience diffi- ble to the feelings of grief and loss ob-
rect associations between degree of culties when they return to school, served in patients with acquired
impairment and psychological adjust- attempt to resume work or leisure ac-

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Editors

Atlas of Amputations and

Editors-in-Chief Planning Committee

American Academy of Orthopaedic Surgeons

Christopher H . Allan, MD Rickard Branemark, MD, MSc, PhD

American Academy of Orthopaedic Surgeons

Donald R. Cummings, CP, LP John R. Fisk, MD

Wayne K. Daly, CPO, LPO Charles M. Fryer, MS

American Academy of Orthopaedic Surgeons

Susan L. Kapp, CPO Sara J. Mulr oy, PhD, PT

American Academy of Orthopaedic Surgeons

Charles H. Pritham, CPO Douglas G. Smith, MD*

Shahan K. Sarrafian, MD Robert L. Waters, MD

American Academy of Orthopaedic Surgeons

American Academy of Orthopaedic Surgeons

American Academy of Orthopaedic Surgeons

American Academy of Orthopaedic Surgeons

Section II: The Upper Limb

American Academy of Orthopaedic Surgeons

15 Wrist Disarticulation and Transradial Amputation: Surgical Management . . . . . 219

Section Ill: The Lower Limb

American Academy of Orthopaedic Surgeons

34 Amputations and Disarticulations Within the Foot: Surgical Management . . . . . . . 429

American Academy of Orthopaedic Surgeons

Section IV: Management Issues

American Acl:lemy of Orthopaedic Surgeons

71 Longitudinal UJ.nar Deficiency . . . . . . . . . . . . . . . . . . . . . . . . . . 869

Appendix: Terminology in Acquired Limb Loss . . . . . . . . . . . . . . . . . . . 945

Index of Manufacturers . . . . . . . . . . . . . .. . . . . . . .. . . . . . .965

American Academy of Orthopaedic Surgeons

American Academy of Orthopaedic Surgeons 3

American Academy of Orthopaedic Surgeons

and external skeletal fixation, aug-

Advances in Level Selection

American Academy of Orthopaedic Surgeons

allowed the skin to be drawn distally

American Academy of Orthopaedic Surgeons

cising the skin longitudinally on each indication with the transection to be

American Academy of Orthopaedic Surgeons

achieved an overall amputation sur-

Surgical Analgesia and

American Academy of Orthopaedic Surgeons

American Academy of Orthopaedic Surgeons

Figure 8 A Gallo-Roman mosaic depict-

Figure 6 "Serratura" (sawing off)-the

American Academy of Orthopaedic Sul'geons

Figure 11 Pare;s kneewalker peg-leg for

American Academy of Orthopaedic Surgeons

Figure 14 Transradial prosthesis de-

American Academy of Orthopaedic Surgeons

American Academy of Orthopaedic Surgeons

American Academy of Orthopaedic Surgeons

American Academy of Orthopaedic Surgeons

American Academy of Orthopaedic Surgeons j

American Academy of Orthopaedic Surgeons

American Academy of Orthopaedic Surgeons

American Academy of Orthopaedic Surgeons

American Academy of Orthopaedic Surgeons 21

Surgical Levels of Amput?1tion length is a basic principle of modern

American Academy of Orthopaedic Surgeons

American Academy of Orthopaedic Surgeons

American Academy of Orthopaedic Surgeons

American Academy of Orthopaedic Surgeons