24A_ Fitting and Training the Bilateral Lower-Limb Amputee _ O&P Virtual Library

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12/16/2014 24A: Fitting and Training the Bilateral Lower-Limb Amputee | O&P Virtual Library

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24A: Fitting and Training the Bilateral Lower-Limb Amputee

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

Douglas G. Smith, M.D.

Ernest M. Burgess, M.D.

Joseph H. Zettl, C.P.

The bilateral lower-limb amputee has throughout recorded medical history presented a

special challenge for the rehabilitation team to provide a degree of mobility that would allow

a more normal place in society. Persons with high-level amputations or congenital limb

deficits that present a similar functional loss can occasionally walk without a prosthesis by

using crutches and a swing-through gait. This requires very good trunk and upper-body

strength, sense of balance, and muscle control. Such ambulation is seen very occasionally

in children and young adults. In most cases, assistive devices are necessary to stand and

walk. Many simple as well as ingenious means have been used by the amputee to move

from place to place. Often the amputees self-designed and made devices that best suited

their needs.

The surgeon, the prosthetist, and the rehabilitation team have at their disposal today a wide

variety of prosthetic and assistive aids for providing comfortable standing and walking. The

remarkable degree of functional restoration now possible can often permit the bilateral leg

amputee to participate in a life-style that socially and vocationally overcomes his physical

handicap.

Bilateral lower-limb amputations are much more frequent currently than in the past largely

secondary to an aging population with an increased incidence of peripheral vascular

disease and diabetes mellitus. Improved medical management is continually increasing life

expectancy throughout the industrialized world. As people live longer, the complications ofdiabetes, peripheral vascular disease, and other chronic medical diseases progressively

increase the frequency of lower-limb loss. In 1985, there were 112,500 nontraumatic lower-

limb amputations in the United States, and 50% of these were in patients with diabetes.

The 3-year survival rate after a major amputation for diabetes or vascular disease is about

50% and is essentially unchanged from the mid-1960s to the early 1980s. Since these

disease states are systemic, studies have shown that approximately 25% of the original

group, or about 50% of surviving patients, can be expected to lose the second limb by 2 to


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areas include the lower fifth of the leg down to but just above the Syme-level ankle

disarticulation, the very short

transtibial amputation above the attachment of the patellar tendon, and the very short

transfemoral amputation in the subtrochanteric region. In each of these instances it is

usually better to elect amputation at a higher level to permit improved prosthetic substitutio

and patient comfort.

Although optimum function is usually the primary concern in amputation, the cosmesis of

the prosthetic limb replacement must also be considered. Syme ankle disarticulation and

knee disarticulation levels have a bulbous end and result in a less aesthetic appearance in

the final prosthesis. Patients with high cosmetic expectations might be dissatisfied with

these levels (Fig 24A-3.[3][3]).

In the geriatric age group, the patient's activity level, ambulatory potential, cognitive skills,vision, and overall medical condition must be evaluated to determine whether the distalmos

level is really appropriate for the patient. In ambulatory patients, the goal is to achieve

healing at the most distal level that can be prosthetically fit and allow successful

rehabilitation. Most unilateral transtibial amputees who were successful prosthetic

ambulators will master bilateral amputee gait if a transtibial or more distal amputation can

be performed on the contralateral limb. The success of rehabilitation decreases dramaticall

if transfemoral or higher-level amputations need to be performed.

In nonambulatory patients, the goal is to obtain wound healing, minimize complications, and

improve sitting balance, transfers, and nursing care. For example, a bedridden patient with

hip and knee flexion contractures might be better served with a knee disarticulation or very

long transfemoral amputation than with a transtibial amputation. On the other hand, a

geriatric patient with a previous transfemoral amputation might be a nonambulator but still

have excellent independent transfers and bathroom skills. If the patient capable of

independent transfers develops contralateral foot gangrene, he might be best served by

preserving all possible length and prosthetic fitting, if the goal is to continue independent

transfers and bathroom activities. Such skills are extremely important in the bilateral

amputee and should be given careful preoperative evaluation, even in nonambulatory

patients. Careful preoperative assessment of the patient's potential and setting realistic

goals can help direct surgical level selection and postoperative rehabilitation wisely.

PROSTHETIC FITTING AND REHABILITATION
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Rapid prosthetic rehabilitation of the multiple-limb amputee ensures the best results in

returning to an active, independent life-style. Speed of recovery is frequently indicative of

how well the patient will be able to perform predetermined rehabilitation goals. This is

particularly important in the management of the majority of amputees we are treating today

the elderly. The psychological and economic benefits to this patient approach are also quite

appreciable. Contemporary prosthetic fitting of the bilateral lower-limb amputee can be

categorized into immediate postsurgical prosthetic fitting (IPPF), early postsurgical

prosthetic fitting, preparatory prosthetic fitting, and definitive prosthetic fitting. Although

managed differently, previous unilateral amputees who later become bilateral and

simultaneous bilateral amputees both benefit from early rehabilitation with controlled weigh

bearing.

Improved wound healing, the prevention of contractures, and early mobilization through the

use of rigid dressings dominate the immediate and early phases. Maturation of the

residual limb by comfortably, increasing weight bearing and initial gait training predominate

in the preparatory prosthetic phase. Cosmesis, durability, and final gait training become

important considerations in the definitive prosthetic phase. Increased sophistication of

current fitting techniques, materials, and available componentry make the correct selection

and application more critical than ever before as the patients proceed through these variou

phases of prosthetic management and training.

Immediate Postsurgical Prosthetic Fitting

Ideally, IPPF with controlled weight bearing is the initial patient treatment of choice,

especially in the young traumatic amputee. The details and benefits of applying a rigid

dressing (i.e., plaster of paris socket) with a pylon extension and prosthetic foot in the

operating room have been adequately documented in the literature. The primary

consideration is achieving rapid, optimal wound healing. This is accomplished by controlling

postsurgical edema without restricting circulation. Tissue support minimizes inflammatory

reaction and reduces phantom pain. The psychological benefits are significant as the patienwakes up with a prosthesis in place of the amputated limb and rehabilitation starts

immediately. Carefully controlled static weight bearing can be initiated the first postoperativ

day or whenever the patient is physically capable of tolerating the procedure. Use of a tilt

table is necessary for the bilateral amputee, with bathroom scales or other pressure-

monitoring devices utilized to help regulate weight bearing. As wound healing

progresses and is monitored at the various cast change intervals, weight-bearing

increments are also accelerated accordingly. Actual ambulation activities are delayed until


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the incisions have healed and sutures have been removed. Patients with simultaneous

bilateral amputations must be advanced more slowly and carefully than the previous

unilateral amputee who can tolerate unrestricted weight bearing on the mature, previously

amputated limb (Fig 24A-4.[4][4]).

If prosthetic pylons have not been utilized initially, manually applied, simulated weight-

bearing activities are administered by the therapist or the patient himself through the cast(Fig 24A-5.[5][5]). The reduction in edema that results from simulated weight bearing

decreases postoperative discomfort. IPPF can be implemented in any hospital setting that

has a trained team of professionals available. The team consists of a surgeon, a prosthetis

a physical therapist, a nurse, and other auxiliary personnel as might be required.

Early Postsurgical Prosthetic Fitting

Under certain conditions, the surgeon may defer application of a rigid dressing 1 to 3 weeks

postsurgically to or near the time when sutures are removed from the surgical incision.

Although we prefer immediate use of rigid dressings, to delay until suture removal is very

common in the bilateral amputee. At this stage, considerable postsurgical edema is usually

evident, and residual-limb or phantom pain can be exaggerated in spite of soft compression

dressings such as an elastic bandage or shrinker sock. In all probability, the patient has

been restricted to bed rest or limited to wheelchair mobility, which leads to physical

decompensation and muscle weakness. In a worst-case scenario, wound healing can be

compromised as a result of this delay.

The early prosthetic fitting techniques employed are the same as for the IPPF. If

considerable edema is evident at the initial application of the cast socket, frequent cast

changes may be indicated until this condition stabilizes. If a cast socket inadvertently come

off the limb, it should not be pushed back on. Damage to the residual limb may result with

associated pain for the patient. A new cast socket must be applied without delay.

Removable cast sockets, in our experience, have been unsuccessful. As the name implies,

they are removable and can come off the residual limb at the most inappropriate time.

The need for daily wound inspection contradicts our position of undisturbed tissue support

and immobilization. Removable rigid dressings must be continuously monitored and require

the complete cooperation of a reliable patient. Regular-interval full-cast changes between 7

and 10 days are adequate for dressing changes unless wound problems require more

frequent attention.
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Soft compression dressings supplemented by an elastic bandage or shrinker sock are less

effective in achieving rapid wound healing. Residual-limb edema associated with discomfor

and phantom pain is frequently evident with this form of patient treatment. It delays the

recovery period unnecessarily and invites further complications in the form of joint

contractures and general physical decompensation, especially in the geriatric patient.

Preparatory Prosthetic Fitting

Preparatory prostheses, also referred to as intermediate or training prostheses, are useful

the volume of the residual limb is expected to decrease rapidly in the near future or if a

gradual reduction of joint contractures will require repeated prosthetic realign-ment. This

is common in simultaneous bilateral amputees who cannot advance their weight bearing as

quickly as unilateral patients.

Such prostheses are also indicated for evaluating a patients potential to safely ambulate or

to demonstrate to a patient the energy and skill requirements associated with the use of

prostheses. If used in this context, preparatory prostheses are indeed justified and present

the best diagnostic and economic tool for measuring a patient's mobility capabilities. The

bilateral amputee greatly benefits from this approach (Fig 24A-6.[6][6]).

Component choice is carefully prescribed in consideration of the particular patient's needs.

Likewise, the prosthetic socket configuration as well as design anticipates the patients

requirements and is the critical contact point of the human anatomy and the mechanical

substitute. Patient comfort will make the decisive difference between acceptance and

rejection of the prosthesis and is therefore a high priority.

Whenever possible, the components of choice should be the same as those anticipated for

the definitive prosthesis to minimize the retraining and relearning required. The economics

of this practice are realistic and obvious. It is frequently prudent to utilize definitive foot-shin

knee components for the preparatory prosthesis and carry them over into the definitive

device. Commercially available, prefabricated, adjustable sockets may warrant

consideration in particular situations when in the opinion of the team this approach is pref-

erable.

Definitive Prosthesis

Definitive prostheses are sometimes erroneously called "permanent" or "final" prostheses.

These are misnomers since all prostheses wear out mechanically or require replacement


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due to deteriorating fit.

Never before in the history of prosthetics have pros-thetists had so many sophisticated

materials and components at their disposal to serve their patients better and more

effectively. High-strength, lightweight components made from titanium and carbon fibers

combined with sockets fabricated with thermoplastic materials or acrylic resins result in a

lightweight prosthetic construction that reduce energy consumption during ambulationactivities. Improved biomechanical fitting principles and static and dynamic test socket

procedures combined with flexible socket construction further enhance patient comfort

and acceptance. Radiographs or xeroradiography can isolate or pinpoint residual-limb fittin

problems. Recent developments in computer-aided design and computer-aided

manufacture (CAD-CAM) open the door to new and exciting possibilities to better serve the

multiple-limb amputee. All this demands greater knowledge and skills on the part of not

only prosthetists but also the entire clinic team, who are responsible for formulating the

prosthetic prescription.

Individual patient needs vary greatly among infants, children, adolescents, adults, athletes,

and active and sedentary geriatric amputees. There are different requirements between

males and females and important considerations to be made for vocational and recreationa

activities. Parents, spouses, relatives, and friends of patients also play an important role

since they influence patients' expectations and reactions to their prostheses and

management. Each new patient requires individual assessment and evaluation to determin

his exact personal needs. While many amputation levels are similar or the same, the

individual patient requirements are vastly different and must be accommodated to be

effective in the overall, total rehabilitation of the patient. A patient must learn to walk before

he can expect to run, if this is even physically possible.

Bilateral amputations can be of an equal level such as foot, ankle, transtibial, knee

disarticulation, transfemo-ral, and hip disarticulation, or any combination of the above. Sinc

it is the surgeon's intent to preserve all joints and all useful length in the residual limb, the

prosthetist is presented with the challenge of varied amputation level combinations where

prosthetic designs must interact effectively.

INFANT AMPUTEES

While statistically a very small group, children with congenital limb deficiencies present

major challenges to the entire rehabilitation team. Depending on the full extent of the

anomaly, infants may face continuous treatment throughout their lifetime to manage the


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disability. Early diagnosis, surgical intervention, and prosthetic fitting have been advocated

As a result, infants are being fitted with lower-limb prostheses as early as 8 months of age

or when they attempt to accomplish a seated or an upright position.

Even high-level amputees as a result of lumbosacral agenesis have been fitted with

specially designed prostheses. The initial prosthetic socket extends to the thorax for

stabilization to allow an upright position and can be fit for sitting as early as 4 to 6months.The socket is mounted on a stable platform to which casters can be mounted fo

mobility. Limited ambulation is accomplished in time, when the socket is mounted on a

swivel walker for self-induced mobility. Following bilateral hip disarticulations, the prosthetic

socket is combined with cosmetically enhanced thigh-shank-foot components that allow

sitting, standing, and some limited ambulation on the principles of a swivel walker. Often

these patients have multiple medical problems that require continued treatment and

monitoring and may interrupt prosthetic management.

Miniaturized, commercially available prosthetic components are very limited for infants. Thi

requires the prosthetist to design and custom-fabricate what is needed. Some upper-limb

components such as manually locking elbow joints can be integrated into lower-limb infant

prostheses. Since structural strength requirements are very minimal, plastic tubing can be

utilized in endoskeletal designs and results in very lightweight, cosmetic appliances.

Recently we have switched to aluminum tubing that is fitted into a larger-size tubing, thus

allowing telescoping length adjustments for growth.

Our current, typical, initial knee disarticulation infant prostheses consist of flexible

thermoplastic sockets mounted in rigid frames. This allows for socket replacements due

to growth without remaking the entire prosthesis. Total-contact socket designs using a sock

interface with the classical Silesian bandage or a modified version thereof has been the

most frequent method of suspension. A miniaturized version of the total elastic suspension

(TES) belt has also proved to be an effective option. Any suspension considerations must

resolve the problems of diapers and thus should be moisture resistant and washable.

Flexible or rigid pelvic band and hip joint suspension or shoulder harness suspension is

seldom indicated in infants. In our experience, it is possible to fit select infants with total-

contact suction suspension as early as 18 to 24 months of age. This eliminates most

auxiliary suspension needs. The prerequisite is that parents be able to apply the prosthesis

correctly. More frequent socket replacements as a result of suction socket fittings are not as

significant as anticipated and should not be a deterrent. Recently, the introduction of the

hypobaric suspension system has provided another suspension option. The system utilizes


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a prosthetic sock that is impregnated circumferen-tially at the midportion with a narrow ban

of flexible silicone that forms an effective seal on the inner socket wall and results in socket

suspension. This system is appropriate even for infants.

The use of stubbies as the initial prosthesis is recommended for all bilateral knee

disarticulation or trans-femoral amputees, regardless of age, who are considered

candidates for ambulation and who lost both legs simultaneously. Stubbies consist ofprosthetic sockets mounted directly over rocker-bottom platforms that serve as feet. The

rocker-bottom platforms have a long posterior extension to prevent the tendency for the

patient to fall backward initially. The shortened anterior portion allows smooth rollover into

the push-off phase. As hip flexion contractures lessen and balance improves, the posterior

rocker extensions can be shortened accordingly. The use of stubbies results in lowering of

the center of gravity, and the rocker bottom provides a broad base of support that teaches

trunk balance and provides stability and confidence to the patient during standing and

ambulation. As the patients confidence and ambulation skills improve, periodic lengthening

of the stubbies is permitted until the height becomes nearly comparable with full-length

prostheses, at which time the transition is attempted. Knee components are usually omitted

for infants since stability and balance are still developing.

The majority of infants, children, and young adults with bilateral knee disarticulation or

transfemoral amputations can generate the energy required to ambulate when wearing

stubbies without needing assistive devices such as crutches or canes. Assistive devices

may be needed for safety and support once the patient has accomplished the transition to

full-length prostheses. Such assistive devices severely compromise upper-limb function an

should be avoided where possible since this alone is a major deterrent to using full-length

prostheses.

Parents like cosmetically pleasing prostheses, and every effort should be made to achieve

this without sacrificing comfort or function. Lightweight exoskeletal designs are also quite

acceptable for use in infants, and the choice should depend on what is considered most

appropriate for a particular patient and parent.

CHILD AMPUTEES

Most children, including high-level bilateral lower-limb amputees, have very high physical

activity levels. They are encouraged to participate in play, sports, and recreation activities

like any other child. As a result many of the children place profound physical demands on

their prostheses. Prostheses in need of major servicing and repairs are a joy to the entire


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so severe that knee instability or flexion contractures prohibit prosthetic fitting, then knee

disarticulation is required on one or both limbs (Fig 24A-9.[9][9]).

As discussed in the infant section, the use of stubbies as the initial prostheses is

recommended for rehabilitation of all bilateral knee disarticulation and transfemoral

amputees who are considered candidates for ambulation and who lost their legs

simultaneously. The majority of children with bilateral knee disarticulation andtransfemoral amputations can generate the required energy to develop ambulatory

capabilities by using stubbies without assistive devices such as walkers, crutches, or canes

(Fig 24A-10.[10][10]). This high performance level is not always sustainable through

adulthood, but diminishes with advancing age when some become marginal users or

abandon the prostheses altogether, except for cosmetic use, in favor of wheelchair mobility

ADOLESCENT AND YOUNG ADULT AMPUTEES

This group of amputees frequently proves the prosthetic team wrong when told of physical

limitations associated with multiple amputations. The news media constantly remind us of

the stunning accomplishments of amputee athletes, including bilateral high-level lower-limb

amputees. These runners, swimmers, skiers, rowers, mountain climbers, basketball players

etc., demonstrate the dangers of stereotyping amputees with outdated classifications.

Experience has proved that patients can excel safely if given the opportunity rather than

being told that they are unable to do so(Fig 24A-11.[11][11]).

Most bilateral amputees perform these extracurricular recreational activities with

conventional prostheses. A few, more competitive amputee athletes may have special

prostheses designed to aid their accomplishments in competitive sports events. There is an

abundance of materials and componentry available from which to select what is most

suitable for a particular amputee. They should be allowed to evaluate different socket

designs, knee components, and feet to determine the best functional combination for their

needs. This is an expensive and time-consuming process but ensures the best results.

Similarly, refinements of socket fit through repeated static and dynamic test socket

procedures, including proper alignment of components, makes for more functional

prostheses(Fig 24A-12.[12][12]).

Suction suspension, including semiflexible transtibial and transfemoral sockets, is preferab

for bilateral amputees, so long as the amputee is able to don and doff the prostheses

effectively without assistance. Flexible brim, ischial containment transfemoral sockets

provide more comfort during ambulation and when seated by providing increased clearance
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in the perineum. It must be noted, however, that there are numerous successful bilateral

transfemoral amputees utilizing quadrilateral or modified quadrilateral suction or

semisuction prostheses. Either these patients have not yet made the transition to ischial

containment socket designs, or they have tried the transition but prefer to remain with their

previous socket designs (Fig 24A-13.[13][13]).

Early flexible inner sockets lacked durability. Surlyn and certain polyethylenes cracked andbuckled under rigorous use and required frequent replacement. Improved working

techniques and better materials have reduced these problems and given the prosthetist a

wider choice of options. The 3S socket design, including the Icelandic Roll-on Suction

Socket (ICE-ROSS) system, provides excellent suspension and minimizes the problem of

excessive perspiration of the residual limbs that is commonly encountered in bilateral

prosthesis use.

Dynamic-response foot and ankle components have a profound impact on socket comfortand the functional capabilities of all lower-limb prosthetic users. Amputees have noted

improvement in proprioceptive feedback improved negotiation of inclines, declines, and

uneven terrain as well as improved impact absorption and reduction of torque and shear

forces. All of these enhance stability and control of prostheses and improve gait. Specia

foot alignment and resistance is required for the bilateral amputee for security and balance

There is an abundance of knee joint components available that aid in stability and function.

For maximum durability, exoskeletal design has the advantage over endoskeletal

systems. For cosmetic appearance, the endoskeletal system has a distinct advantage and

is therefore favored by many females. Postfitting realignment procedures are performed

much more conveniently and expediently with endoskeletal designs than with exoskeletal

systems that require major labor-intensive reworking procedures to achieve alignment

corrections.

Bilateral young transtibial amputees usually become excellent ambulators with a relatively

normal gait without the use of external aids. Similarly, persons with bilateral partial-foot

amputations, Syme ankle disarticulations, or a combination of these levels accomplish a

near-normal gait. Knee disarticulation or transfemoral amputees with contralateral transtibia

or more distal amputation also become accomplished ambulators but frequently prefer a

cane or other assistive device. Most bilateral amputees who have lost one knee limit their

daily ambulation activities and have sedentary jobs.

The simultaneously acquired bilateral knee disarticulation or transfemoral amputee requires


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fitting with stubbies as the initial prostheses, as previously discussed. In our experience,

most adults with acquired bilateral transfemoral amputations fail to become consistent

wearers of full-length prostheses but continue the use of stubbies for their daily ambulation

activities. They may elect to wear the full-length prostheses for special events or cosmetic

reasons only. The longer lever arm, balanced thigh musculature, and end-bearing capacity

of the knee disarticulation makes bilateral full-length prosthetic use easier than for the

bilateral trans-femoral amputee, but the principles and training are very similar (Fig 24A-14[14][14]). The accomplished user of bilateral transfemoral prostheses typically uses a cane

and has midthigh or longer amputation levels. This patient was usually involved in

recreational or sports activities prior to the amputations, is physically slim and fit, and has

high endurance and good motivation. Full-length prostheses are usually designed to shorte

the patient's stature slightly because balance is improved by lowering the center of gravity

(Fig 24A-15.[15][15]). Use of a stance-control or manual-locking knee is reserved for the

shorter of the residual limbs. Different knee mechanisms can and should be utilized asrequired, but they must be tested and evaluated during trial ambulation. Foot and ankle

components should be of the same type and function for both limbs and have a stiffer

plantar flexion resistance than is required in unilateral cases. Larger foot size may improve

support and stability. The patient must be able to achieve a seated and standing position

independently and in less-than-ideal locations. The amputee must also be trained to return

to the standing position from the ground as occasionally would be required after a fall.

Bilateral transfemoral prosthetic users require a great deal of gait training by a qualified

physical therapist. Negotiation of stairs, inclines, declines, and uneven terrain are complexchallenges that must be learned and practiced by the patient to become an accomplished

ambulator (Fig 24A-16.[16][16]).

There are some possible variations in the rocker bottoms of stubbies. The use of SACH

feet with the toes pointing posteriorly has been advocated by some for a smoother gait. We

have utilized rocker bottoms incorporating the Greissinger foot multiaxial ankle system (Fig

24A-17.[17][17]) and more recently the Flex Walk Foot fitted to tennis shoes. One triple

amputee with a very short transfemoral amputation on one side is capable of briskly walkin

2 miles daily for exercise. He prefers stubbies over full-length prostheses, which require

much higher energy output, are cumbersome, slow him down, and instill a constant fear of

falling (Fig 24A-18.[18][18]). This experience is very common with the use of full-length

transfemoral prostheses and restricts the majority to ambulation with stubbies only.

Adults with acquired bilateral hip disarticulation rarely become effective ambulators, but the

still may request special-purpose prosthetic fittings. Specially designed and fitted sockets to
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allow for more comfortable seating can be provided. Full-length functional prostheses are

primarily for cosmetic appearance while seated in a wheelchair, but it is possible for the

patient to stand in these prostheses and initiate voluntary mobility on the principles of a

swivel walker. A particularly strong patient can also accomplish a swing-through gait wit

the aid of crutches (Fig 24A-19.[19][19]).

GERIATRIC AMPUTEES

The great majority of bilateral lower-limb amputees today are the elderly who lose their

limbs secondary to diabetes and vascular disease between the ages of 55 and 95 years. In

general, dismissing these patients as poor prosthetic candidates is a grave mistake and

compromises the rehabilitation potential when immediate postsurgical treatment is delayed

Lack of exercise and mobility will encourage joint contractures, weaken the patient, cause

loss of independence, bring on depression, and may even become life-threatening. No

patient group benefits more from immediate postsurgical prosthetic fitting, including early

fitting of preparatory or definitive prostheses, than the geriatric bilateral amputee. The

challenge of rehabilitating these patients is frequently complicated by the presence of other

illnesses. Diabetes, chronic infection, kidney disease, cardiovascular disease, respiratory

disease, arthritis, and impaired vision are complicating factors that require careful

consideration when evaluating patients. Delayed wound healing, slowly healing lesions, an

neuropathy warrant additional consideration. Of these complicating factors, diabetes

appears to be the leading cause of second limb loss.

Fortunately, the time interval between the first and second limb loss, which can be months

or perhaps years, makes learning to ambulate easier for the patient than if both limbs are

lost simultaneously (Fig 24A-20.[20][20]). Chronologic age alone should not determine

whether an amputee is a prosthetic candidate. A 90-year-old patient can be in better

physical shape than a 50-year-old and use prostheses accordingly. While the patient

must be able to understand and follow instructions for proper use of the prosthesis, this ma

not be always the case immediately preceding or following amputation when systemictoxicity from an infected limb may cause the patient to act temporarily confused or unaware

of the ongoing proceedings. Sometimes patients are wrongly diagnosed as prosthetic

noncandidates and denied prostheses. We must give the patient the benefit of the doubt

and provide at least preparatory prostheses to evaluate ambulation potential. Even if

prostheses are used only to assist in transfer activities, they are justified.

Preoperative and postoperative patient education is an important adjunct to rehabilitation.


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Teaching a patient proper hygiene and care of the residual limbs and the prostheses is vita

Amputee support groups, now available in many localities, are a great benefit to patients in

learning about their disability and in being able to discuss matters with other amputees that

they may be reluctant to discuss with clinic team members. Older patients require much

more time, understanding, patience, and encouragement. They thrive on praise, and even

small improvements give encouragement and aid in progress. They are frequently forgetful

and need to be reinstructed frequently. Spouses and other family members should be

encouraged to participate during fitting and training sessions. Their input is important, and

their concerns should be addressed in detail.

Prosthesis design and componentry must be based on careful individual evaluation of all

pertinent factors. The most sophisticated prosthesis with hydraulic or pneumatic swing-

phase control, rotators or torque absorbers, and energy-storing foot is totally inappropriate

we are dealing with a marginal ambulator who uses the prosthesis on a very limited indoor

basis. Any type of prosthesis is inappropriate if the patient is unable to don and doff it

properly. Bilateral transfemoral prostheses are too difficult to manage for most geriatric

patients and, if requested, are primarily for cosmetic effect while using a wheelchair. Even

stubbies are often too difficult for this group to master, and it is a very rare exception to find

someone willing to try and to succeed in ambulating with them regularly (Fig 24A-21.[21][21]

Use of a transfemoral and transtibial prosthetic combination is limited to only a few very

energetic patients and then for only limited use around the house.

Socket design must be such that the patient can don and doff the prosthesis independently

For transtibial prostheses, this may require that special pull-on loops be attached to the

socket or liner for patients with arthritis of the hands. Similarly, a patient must be able to

properly install a wedge suspension system in a PTS design, or other alternatives must be

utilized. A neo-prene suspension sleeve is an excellent means of auxiliary socket

suspension if the patient can apply it properly. If the patient cannot handle buckles, Velcro

closures should be substituted. Side joints and thigh lacers are infrequently required for an

unstable knee or very short residual transtibial limb. They greatly complicate donning theprosthesis, and should be avoided if other alternatives exist. Little frustrations can lead to

total rejection of the prostheses and must be avoided. The basic rule is to keep them as

simple as possible.

Although suction socket suspension is the preferred means of suspension, the bilateral

geriatric amputee can seldom master the conventional donning technique. An alternative

method that merits consideration is use of the liquid-powder, wet-fit method, in which the


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patient liberally applies a special liquid lubricant that allows donning the prosthesis. This

lubricant rapidly dries into a powder that allows retention of the socket by suction. Another

option is to provide flexible, roll-on silicone liners that allow donning and doffing while

seated. Hyperbaric socket suspension offers another excellent option.

The majority of bilateral geriatric transtibial amputees master ambulation with the aid of a

walker or cane. An amputee with transtibial amputation and a more distal level on thecontralateral side almost routinely achieves ambulatory status with or without a walking aid

(Fig 24A-22.[22][22]). Prostheses for geriatric amputees should be made as light as possible

with contemporary techniques. They should be of relatively simple design and not contain

superfluous components that may be of questionable benefit to limited ambulators.

Occasionally geriatric patients with bilateral congenital deformities are encountered who

have remained active ambulators. For these rare patients, custom-designed prostheses are

required. Lightweight construction can prolong prosthetic use and ambulation (Fig 24A-23.[23][23]).

SHOES FOR AMPUTEES

It is noteworthy that Kegel reports the recent development of special dress shoes for

amputees that are very lightweight, flexible, and have a soft compressible heel to dampen

impact at heel strike. The shoes are manufactured by Bally and look like any other regular

dress shoe. Kegel states that "there are shoes available for soccer, tennis, skiing and otherspecial requirements, but none for prostheses users." This new development remedies this

need.

SUMMARY

The bilateral lower-limb amputee presents complicated problems for mobility and

ambulation. The tremendous developments of recent years offer these individuals much

greater functional potential. By applying the surgical, prosthetic, and rehabilitationtechniques currently available, the bilateral lower-limb amputee can often achieve a

remarkable degree of functional ambulation.

References:

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664.


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amputees: A survey.Arch Phys Med Rehabil 1980 61:256-264.

40. Kokegei D, Dotzer R: Prosthetic management of the lower limb after traumatic

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42. Kruger LM: The use of stubbies for the child with bilateral lower-limb deficiencies.

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economic value. JBone Joint Surg [Am] 1969 51:1135-1138.

45. Lehneis HR: A thermoplastic structural and alignment system for below-knee

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47. Lippert FG III, Burgess EM, Starr TW: Physiologic suspension factors in below-knee

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48. Long IA: Normal shape-normal alignment (NSNA) above-knee prosthesis. Clin

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49. Macfarlane PA, Nielsen DH, Shurr DG, et al: Gait comparisons for below-knee

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50. Malone JM, Moore W, Leal JM, et al: Rehabilitation for lower extremity amputation.

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51. Malone JM, Moore WS, Goldstone J, et al: Therapeutic and economic impact of a

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52. Manella KJ: Comparing the effectiveness of elastic bandages and shrinker socks for

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53. Marquardt E: The multiple limb-deficient child, in American Academy of Orthopedic

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54. Marshall K, Nitschke R: Principals of the PTS BK prosthesis. Orthop Prosthet

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55. Mauch HA: Stance control for above-knee artificial legs: Design consideration in the S

N-S knee. Bull Prosthet Res 1968 10:61-71.


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56. Mazet R, Schiller FJ, Dunn OJ, et al: The Influence of Prostheses Wearing on the

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60. Michael JW: Energy storing feet: A clinical comparison. Clin Prosthet Orthot 1987

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67. Pohjolainen T, Alaranta H, Wikstron J: Primary survival and prosthetic fitting of lower

limb amputees. Prosthet Orthot Int 1989 13:63-69.

68. Radcliffe C, Foort J: The Patellar-Tendon-Bearing Be-low-Knee Prosthesis. Berkeley,

University of California Biomechanics Laboratory, 1961.

69. Romano RL, Zettl JH, Burgess EM: The Syme's amputation: A new prosthetic

approach. Inter-Clin Info Bull 1972 9:1-9.

70. Russell JE: Congenital absence of sacrum and lumbar vertebrae: A case report. Inter-

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71. Saadah ESM: Bilateral below-knee amputee 107 years-old and still wearing artificial

limbs. Prosthet Orthot Int 1988 12:105-106.

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73. Saunder CG: Computer Aided Socket Design Teaching Manual. Vancouver, Medical

Engineering Research Unit, Shannesse Hospital, 1984.

74. Schuch CM: Modern above-knee fitting practice. Prosthet Orthot Int 1988 12:77-90.

75. Sowell TT: A preliminary clinical evaluation of the Mauch hydraulic foot-ankle system.

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76. Staats T: Advances in prosthetic techniques for below knee amputations. Orthopedics

1985 8:249.

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78. Swanson VM: Technical note: An alternative below-knee ultra lite technique. JProsthe

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80. Van der Waarde T: Ottawa experience with hip disarticulation prostheses. OrthotProsthet 1984 38:29-33.

81. Varnau D, Vinnecour K, Luth M, et al: The enhancement of prosthetic fit through

xeroradiography. Orthot Prosthet 1985 39:14.

82. Waters RL, Perry J, Antonelli D, et al: Energy cost of walking amputees: The influence

of level of amputation. JBone Joint Surg [Am] 1976 58:42-46.

83. Watkins AL, Liao SJ: Rehabilitation of persons with bilateral amputations of the lower

extremities. JAMA 1958 166:1585-1586.

84. Weiss M: Myoplasty, immediate fitting, ambulation. Presented at the WorldCommission on Research in Rehabilitation. Tenth World Congress of the International

Society, Wiesbaden, Germany, 1966.

85. Weiss M: The Prosthesis on the Operating Table From the Neurophysiological Point o

View: Report of Workshop Panel on Lower Prosthetics Fitting. Washington, DC,

National Academy of Sciences, 1966.

86. Whitehouse FW, Jurgensen C, Block MA: The later life of the diabetic amputee:

Another look at the fate of the second leg. Diabetes 1968 17:520.

87. Wilson AB Jr, Schuch MC, Nitschke RO: A variable volume socket for below knee

prostheses. Clin Prosthet Orthot 1987 11:11-19.

88. Wolf E, Lilling M, Ferber I, et al: Prosthetic rehabilitation of elderly bilateral amputees.

Int J Rehabil Res 1989 12:271-278.

89. Wu Y, Brncick MD, Krick HJ, et al: Technical notes: Scotchcast PVC interim prosthesis

for below knee amputees. Bull Prosthet Res 1981 18:40-45.

90. Wu Y, Flanigan DP: Rehabilitation of the lower-extremity amputee with emphasis on a


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removable below-knee rigid dressing, in Gangrene and Severe Ischemia of the Lower

Extremities. New York, Grune & Stratton, 1978.

91. Wu Y, Keagy RD, Krick HJ, et al: An innovative removable rigid dressing technique for

below-the-knee amputation. JBone Joint Surg [Am] 1979 61:724-729.

92. Wytch R, Mitchell CB, Wardlaw D, et al: Mechanical assessment of polyurethane

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93. Zettl JH: Experience with endoskeletal prostheses for lower extremities. Bull Prosthet

Res 1972 10:52-66.

94. Zettl JH: Immediate postoperative prostheses and temporary prosthetics, in Moore

WS, Malone JM (eds): Lower Extremity Amputation. Philadelphia, WB Saunders Co,

1989, pp 177-214.

95. Zettl JH: Immediate postsurgical prosthetic fitting: The role of the prosthetist.Am J

Phys Ther 1971 51:144.

96. Zettl JH, Burgess EM, Romano FL: The interface in the immediate postsurgicalprosthesis. Bull Prosthet Res 19698:10-12.

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

References

1. ^Fig 24A-1. (www.oandplibrary.org)















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READABILITY An Arc90 Laboratory Experiment








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