Role of Gritti-Stokes amputation in peripheral vascular disease.

The perigenicula lower limb amputations performed for peripheral vascular disease in Nottingham between April 1987 and September 1992 were reviewed. Of the 434 amputations, 173 were below-knee amputations (BKA), 144 Gritti-Stokes amputations (GSA) and 117 above-knee amputations (AKA). The 30-day mortality was significantly greater for AKA patients than either GSA or BKA patients. There was no difference in mortality within 30 days of amputation between GSA and BKA. Re-amputation rate to a more proximal level was significantly higher in BKA compared with GSA. Mobility after prosthetic rehabilitation was assessed using the Stanmore grading. A greater number of patients achieved mobility grade III and above in the GSA and BKA groups when compared with the AKA group, but there was no significant difference between GSA and BKA groups. At follow-up, a median of 23 months after amputation, there was a tendency for more patients to have given up using their limb prosthesis in the GSA group than either the BKA or AKA groups. However, there remained no significant difference between the BKA and GSA groups in the numbers of patients who remained successfully rehabilitated to Stanmore grade III or above. When a BKA is not possible, GSA offers a better prospect for rehabilitation compared with AKA in patients with occlusive arterial disease.

Upper limb traumatic amputees. Review of prosthetic use.

The prosthetic status of the traumatic upper limb amputees was reviewed. Fifty-five upper limb amputees were reviewed using a detailed questionnaire, telephone or clinic review and by case note study. Twenty-three patients were traumatic amputees and 32 were congenital amputees. The amputees' function, prosthetic use and satisfaction were evaluated and this formed the basis of a scoring system. The traumatic group were less satisfied with their prosthesis and their functional ability was poorer, especially in the use of the myoelectric prosthesis. Traumatic amputees were their prosthesis for an average of 6.5 hours per day compared to 9.3 hours in the atraumatic group. None of the traumatic amputees fitted after 12 weeks returned to gainful employment. Early prosthetic fitting, rehabilitation and post-traumatic counselling are advocated in upper limb traumatic amputees in order to achieve an optimum prosthetic benefit for the patient.

Stair ambulation in persons with transtibial amputation: an analysis of the Seattle LightFoot.

The purpose of this study was to document gait patterns in a group of individuals with transtibial amputations (TTA) during stair ambulation, and to identify the functional limitations associated with this task. Ten persons with TTA fitted with a Seattle LightFoot prosthetic component, and 14 nondisabled subjects participated in this study. Electromyographic activity (EMG) of the vastus lateralis (VL), rectus femoris (RF), gluteus maximus (GMAX), semimembranosus (SMEMB), biceps femoris long head (BFLH), and biceps femoris short head (BFSH) was assessed using indwelling wire electrodes during ascending and descending stairs. Lower limb kinematics (VICON) and stride characteristics (Footswitch Stride Analyzer System) also were collected. Stride characteristics revealed that those with TTA had a significantly slower rate of stair ambulation and demonstrated stance phase asymmetry between limbs compared to the nondisabled. Kinematic analysis determined significant limitations in prosthetic ankle motion, which necessitated compensatory functions at the hip and knee to accomplish stair ascent and descent and resulted in significantly greater muscular effort (increased EMG intensity and duration) compared to nondisabled.

Analysis of a vertical compliance prosthetic foot.

Mechanical testing of the Re-Flex VSP Foot was conducted on the pylon alone and on the pylon and forefoot system. Values for spring and damping correspond well to values reported in the literature for spring and damping of physiological limbs. Pylon stiffness was 49.4 kN/m for a 600 N subject and 91.4 kN/m for an 800 N subject. The vertical stiffness of the pylon and forefoot together was 31.9 kN/m and 37.8 kN/m, respectively. Gait parameters of two persons with transtibial amputation who used vertically compliant feet for walking, jogging in place, and curb descent were investigated. Ground reaction forces, vertical trunk movement, event timing, and pylon compression were observed. The spring-loaded telescoping pylon was immobilized for half the trials. The trials were repeated the following week with the vertical compliance feature mobilized. Significant differences in vertical trunk motion and timing were found between the prosthetic limb and normal limb, as might be expected. Vertical compliance appeared to cause little change in gait parameters during normal walking. The largest differences appeared during the higher impact events such as fast walking and jogging in place.

Avaliacao funcional do amputado de membro inferior ao final do processo de reeducacao da marcha com protese / Functional evaluation of the amputated one of inferior member to the end of the process of re-education of the march with prosthesis

O tratamento fisioterapico do amputado de membro inferior tem como objetivo levar o paciente a recuperar o maximo de sua capacidade funcional. Neste trabalho propomos um protocolo de avaliacao funcional do paciente, ao final do processo de reeducacao da marcha, segundo as habilidades, dificuldades, limitacoes e expectativas do paciente

Rehabilitation of the older lower limb amputee: a brief review.

OBJECTIVE: To review outcomes, over the last 25 to 30 years, of prosthetic rehabilitation in the older patient with a major lower limb amputation. DESIGN: Literature review of articles and reports about lower limb amputation, using key words elderly amputee rehabilitation, and lower limb amputation, through a computerized Medline Search. CONCLUSIONS: Age alone should not determine prosthetic rehabilitation. Comorbidities and general health are important determinants. The more proximal the amputation, the more energy is demanded from the cardiovascular and pulmonary systems for prosthetic gait. Changes in surgical technique and revascularization procedures have allowed preservation of the knee, which decreases energy demands and allows more older patients a chance to undergo rehabilitation for ambulation. Although the ratio of below knee (transtibial) amputations to above knee (transfemoral) amputations has increased, overall postsurgical mortality (10-30%), long term survival (40-50%@2 years, 30-40%@5 years), and risk of loss of the contralateral leg (15-20%@2 years) has not changed significantly since the 1960s. Despite the lack of improvement in survival as a result of the systemic vascular disease, the older patient can benefit from rehabilitation efforts with goals of prosthetic ambulation or simply cosmesis. The shortened longevity emphasizes the need for timely rehabilitation to enhance the quality of the remaining years. The geriatrician can add to the presurgical care and preprosthetic phase of rehabilitation by attention to the problems common to the older patient, i.e., multiple comorbidities, polypharmacy, immobility, and depression. Postoperatively, early mobilization is crucial to avoid the deleterious effects of immobility in the older person. Further investigations into the psychosocial issues and cost benefits of limb loss and prosthetic rehabilitation are needed. In addition, comparison of the various rehabilitation protocols and the impact of cardiac resting before rehabilitation are needed.

Predicting prosthetic rehabilitation outcome in lower limb amputee patients with the functional independence measure.

OBJECTIVE: To determine the value of the Functional Independence Measure (FIM) score as a prognostic indicator for prosthetic use in the lower limb amputee patient. DESIGN: Cohort study of 41 patients with lower limb amputations. SETTING: University hospital rehabilitation unit. MAIN OUTCOME MEASURES: FIM motor subscore and Houghton Scale for prosthetic use. RESULTS: FIM score on admission did not correlate with prosthetic use as measured by the Houghton Scale; however, FIM motor subscore at discharge did. CONCLUSION: The admission FIM score is not useful in predicting successful prosthetic rehabilitation in lower extremity amputee patients. Only the motor subscore at discharge correlates with the use of prosthesis.

Rehabilitation in limb deficiency. 3. The geriatric amputee.

This self-directed learning module highlights advances in the evaluation and management of the geriatric amputee. It is part of the chapter on rehabilitation in limb deficiency in the Self-Directed Physiatric Education Program for practitioners and trainees in physical medicine and rehabilitation. This article discusses the impact of aging and comorbid factors on the function of the geriatric amputee. Specific clinical examples are provided to illustrate management issues. Advances that are covered include prosthetic management and modifications for the elderly.

Rehabilitation in limb deficiency. 4. Limb amputation.

This self-directed learning module highlights new advances in this topic area. It is part of the chapter on rehabilitation in limb deficiency in the Self-Directed Physiatric Education Program for practitioners and trainees in physical medicine and rehabilitation. This article reviews the phases of amputation rehabilitation from preoperative stages to community reintegration and long-term follow-up. The various indications for artificial limb components for the upper and lower limb amputee and the expected functional levels based on level of amputation are discussed. New concepts of critical pathways are also introduced as guidelines in optimizing the rehabilitation of the amputee. The reader is directed to other relevant literature as well, in an attempt to enhance knowledge in this area of rehabilitation.

Rehabilitation in limb deficiency. 1. Gait and motion analysis.

This self-directed learning module highlights new advances in this topic area. It is part of the chapter on rehabilitation in limb deficiency in the Self-Directed Physiatric Education Program for practitioners and trainees in physical medicine and rehabilitation. This article discusses normal gait, the influence of prosthetic alignment on amputee function, and the effects of prosthetic components on the metabolic costs and the biomechanical function of the amputee. The biomechanics of normal ambulation are presented as a background to enable the practitioner to gain an understanding of the typical gait adaptations that occur in below-knee and above-knee amputees. The effects of newer prosthetic components and socket designs on the biomechanical adaptations are reviewed. The metabolic costs of amputee ambulation are significantly greater than normal. The theoretical mechanisms for this are discussed, and the effects of newer socket designs, ultra-light-weight components, and energy-storing prosthetic components are presented.

Rehabilitation in limb deficiency. 2. The pediatric amputee.

This self-directed learning module highlights advances in the evaluation and management of the pediatric amputee. It is part of the chapter on rehabilitation in limb deficiency in the Self-Directed Physiatric Education Program for practitioners and trainees in physical medicine and rehabilitation. This article discusses the etiology and terminology of childhood limb deficiency. Developmental milestones are used as a guide to prescribing prosthetic devices for children, and tables suggesting such guidelines are included. Specific clinical examples are provided to illustrate management issues. Advances that are covered include limb-sparing procedures in the management of lower extremity malignancy.

Postoperative transcutaneous oxygen measurement in the prediction of delayed wound healing and prosthetic fitting among amputees during rehabilitation. A pilot study.

Postoperative assessment of amputation wound healing remains largely subjective in nature, being based on the physician's clinical judgement. These considerations significantly impact on the rehabilitation course, as premature prosthetic fitting may result in wound breakdown. Alternatively, delayed healing may result in prolonged hospital length of stay. Few attempts have been made to correlate objective parameters of limb perfusion with amputation wound healing or prosthetic fitting outcome during the rehabilitation phase of treatment. A pilot study was conducted, in which the transcutaneous oxygen monitor, a noninvasive device measuring transcutaneous partial pressure of oxygen (tcpO2), was applied to the stumps of 11 consecutive above-or below-knee amputees admitted for rehabilitation after amputation. All patients were tested within 1 wk of admission and 45 days of amputation. The treatment team was blinded as to the test results. A direct correlation was observed between wound healing outcome and tcpO2 results (Fisher's exact test [FET], P = 0.03), and no patient with a tcpO2 of < or 15 mm Hg healed during their rehabilitation stay (FET, P = 0.006). TcpO2 of < or = 15 mm Hg was significantly correlated with prolonged length of stay (Point Biserial Correlation Coefficient [rpbi], = -0.835; P = 0.01), delayed prosthetic fitting (rpbi = 0.742; p = 0.01), and poorer wound healing at admission (rpbi = 0.932; P = 0.001). Postoperative tcpO2 measurement may have use in objectively identifying patients at greater risk of delayed wound healing and prosthetic fitting, although further study is warranted.

[Results of transgenicular amputation with dorsal skin-muscle flap-plasty in patients in the final stage of arterial occlusive disease]. / Ergebnisse der transgeniculären Amputation mit dorsaler Haut-Muskel-Lappenplastik bei Patienten im Endstadium der arteriellen Verschlusskrankheit.

A modified technique of knee joint disarticulation by using a dorsal musculocutaneous flap of the gastrocnemius muscle was first described in 1985. The retrospective operative results in 60 patients with gangrene due to peripheral vascular disease (mean age 69 +/- 12 [43-93] years, 29 female, 31 male) with 62 knee disarticulations are reported. After a mean survival period of 18 (1-53) months 47% (n = 28) of the patients had died due to cardiopulmonal reasons after a mean follow-up period of 26 (3-71) months. In-hospital 48 day-lethality was 10%. 9 patients (15%) were re-amputated at above-knee level and in 5 patients operative revisions of the soft tissue were performed. After discharge from hospital 29 of 54 patients (54%) were able to walk with the aid of a prosthesis. We conclude that knee disarticulation with the use of a myocutaneous gastrocnemius flap is a safe and functionally acceptable operative method in high-risk vascular patients.

[Walking ability in bilateral leg amputees following prosthetic rehabilitation]. / Gehfähigkeit beidseits Beinamputierter nach prothetischer Versorgung.

Between January 1989 and March 1993 117 patients were treated after acquired bilateral amputation of the lower extremities at the "Klinik und Poliklinik für Technische Orthopädie und Rehabilitation der Westfälischen Wilhelms-Universität Münster", Germany. Information from patients files and telephone interviews were collected to assess the degree of use of prostheses. All patients with levels of amputation not higher than above-knee on one side and hind-foot on the other side used their prostheses for daily walking. None of the patients with bilateral knee-disarticulation or higher levels of amputation used prosthetic devices for regular walking. In patients with amputation levels between these extremes the result of rehabilitation with prostheses is determined mainly by the cause of the amputation.

[The geriatric amputee after discharge from successful rehabilitation--a study of former patients of the "Eifelhöhenklinik" rehabilitation center in Nettersheim-Marmagen]. / Der geriatrisch Amputierte nach Entlassung aus erfolgreicher Rehabilitation--Eine Untersuchung über ehemalige Patienten der Rehabilitationsklinik "Eifelhöhenklinik" in Nettersheim-Marmagen.

Based on two self-developed questionnaires, 110 successfully rehabilitated geriatric amputees were examined relative to their motives for continuing to use their prostheses post discharge, or for giving them up in favour of a wheelchair, respectively. Of these 110 patients, 24 reported to be using wheelchairs, 16 said they are using both, and 70 claimed to be using their prostheses most of the time; it however appeared from the control questions as well as information given by relatives that only 53 of these 70 persons were actually using their prostheses most of the time. The main motive for continued use of the prostheses was the desire to be independent, hence to lead an active life; a second major motive was a perception of being full of energy and enterprise, notwithstanding the fact that their actual walking results had not improved but even deteriorated. Those who used wheelchairs did not abandon their learned ability to walk with prostheses because they felt too ill or too weak, but did so because the wheelchair enabled a more comfortable way of life.

Prosthesis training as a context for studying occupational forms and motoric adaptation.

OBJECTIVES: Occupational therapy authors frequently emphasize the importance of the use of objects in the development of motor skill. This study investigated the use of object-produced visual input in learning control of flexion and extension of an above-elbow training prosthesis. METHOD: Fifty-two male college students were randomly assigned to two training procedures: (a) two 1.5-min periods in which they used a flashlight attached to the hook of the prosthesis to connect dots on paper with light, or (b) the same time periods in which they had the opportunity to practice moving an equally weighted prosthesis, but without the light or dots. To assess motoric adaptation after training under one of the two conditions, each subject traced a continuous line through a maze with a pen attached to the hook. Deviations from the line were measured reliably. RESULTS: Data analysis with a Mann-Whitney test revealed that subjects in the group that trained with added materials traced with significantly more skill than subjects in the other group (one-tailed U = 225.5, p = .02). CONCLUSION: As predicted by occupational therapy theory, the object-produced visual input enhanced the learning of a motor skill relevant to rehabilitation. Although there is a need for more study across different occupations and populations, clinicians are urged to consider the possible benefits of the use of objects in the development of motor skills, as opposed to objectless exercise. Prosthetic training provides a useful context for future research addressing theoretical issues in motor learning.

Successful voluntary grasp and release using the cookie crusher myoelectric hand in 2-year-olds.

We examined the ability of two 2-year-old children with limb deficiency to demonstrate grasp and release while using the cable-operated voluntary opening hook-hand and the externally powered single-site myoelectric Cookie Crusher system. The Cookie Crusher circuit is an electronic package that causes the prosthetic hand to open in response to muscle contraction and closes (as if crushing a cookie) when the muscle is relaxed. Both children were consistently good prosthetic wearers, beginning with their initial passive devices and progressing through their cable-operated hooks and hands. However, before they began to use the Cookie Crusher (Subject 1 at 25 months, Subject 2 at 30 months), neither had developed voluntary grasp or release in spite of 3 to 12 months' use of cable-operated voluntary opening prehensors. Both children developed a voluntary grasp and release for the first time within minutes of starting to use the Cookie Crusher. The more adept of the two children, a girl with a traumatic above-elbow amputation, showed prehensile function with the Cookie Crusher during play. The spontaneous use of the Cookie Crusher may be related to the predominance of associated reactions in young children. As children play bimanually, associated movements of the nondominant extremity often occur and, in the case of children with limb deficiencies fitted with Cookie Crusher prehensors, these associated reactions result in successful grasp and release. We will continue to follow the choice of effective control schemes in these children as they mature.