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PubMed2004

Reliability, validity, and responsiveness of the locomotor capabilities index in adults with lower-limb amputation undergoing prosthetic training.

OBJECTIVE: To assess the reliability, validity, and responsiveness of both the standard and revised Locomotor Capabilities Index (LCI) in people with lower-limb amputation who undergo prosthetic training. DESIGN: Reliability and validity study. SETTING: Two freestanding rehabilitation centers. PARTICIPANTS: Fifty inpatients with a recent unilateral lower-limb amputation. INTERVENTIONS: Not applicable. Main outcome measures The standard LCI and a new version with a 5-level ordinal scale (LCI-5) were tested for internal consistency, test-retest reliability, ceiling effect, and effect size. The construct validity of both versions was analyzed by correlation with the Rivermead Mobility Index, a timed walking test, and the FIM instrument. RESULTS: The Cronbach alpha of both LCI versions was.95. The item-to-total correlations (Spearman rho) ranged from.50 to.87 (P<.0001 for all). The percent agreement and kappa values for the item scores ranged, respectively, from 78.4% to 100% and.58 to 1.00 in the LCI, and from 75.7% to 97.3% and.54 to.96 in the LCI-5. The intraclass correlation coefficient (model 2,1) for the total scores was.98 for both versions; the Bland-Altman plot revealed no systematic trend for either version. Both the LCI and LCI-5 correlated with all criterion measures (rho range,.61-.76), with the LCI-5 showing a larger effect size during the rehabilitation period and a lower ceiling effect. Patients with transtibial amputation were more independent in performing activities than were those with transfemoral amputation; their locomotor capability negatively correlated with age. CONCLUSIONS: Both the LCI and LCI-5 captured the global locomotor ability of people with lower-limb amputation during prosthetic training. The new LCI-5 presents similar and sometimes better psychometric properties than the standard LCI.

Activities of Daily Living↗
PubMed2004

Daily physical activity and heart rate response in people with a unilateral transtibial amputation for vascular disease.

OBJECTIVE: To study the activity level and heart rate response, objectively measured during normal daily life, of persons with a unilateral transtibial amputation for vascular disease. DESIGN: Case comparison. SETTING: General community, daily life in the Netherlands. PARTICIPANTS: Nine subjects with a unilateral transtibial amputation for vascular disease (convenience sample) and 9 control subjects without known impairments (matched for sex, age, social situation, employment). INTERVENTIONS: Not applicable. MAIN OUTCOME MEASURES: Duration of dynamic activities, body motility (the intensity of body movement, measured with accelerometry), and heart rate (on 2 consecutive days). RESULTS: Persons with an amputation were less active than the comparison subjects (4.3% vs 11.4% of a 48-h period, P=.007). Body motility during walking was lower in the amputee group (.111 g vs.147 g, P=.003). No differences between groups were found in normalized heart rate during walking. In the amputee group, a strong relationship was found between body motility during walking and the percentage of the day that the subject walked (r=.88, P=.002). No relationship was found between the percentage of the day that persons with an amputation were active and data from disability questionnaires. CONCLUSION: Persons with a unilateral transtibial amputation for vascular disease were considerably less active than persons without known impairments. Heart rate response during walking of the amputee group did not differ from the response in the comparison group.

Activities of Daily Living↗
PubMed1997

Randomised trial of epidural bupivacaine and morphine in prevention of stump and phantom pain in lower-limb amputation.

BACKGROUND: Epidural analgesia before limb amputation is commonly used to reduce postamputation pain. But there have been no controlled studies with large numbers of patients to prove such a pre-emptive effect. We investigated whether postamputation stump and phantom pain in the first year is reduced by preoperative epidural blockade with bupivacaine and morphine. METHODS: In a randomised, double-blind trial, 60 patients scheduled for lower-limb amputation were randomly assigned epidural bupivacaine (0.25% 4-7 mL/h) and morphine (0.16-0.28 mg/h) for 18 h before and during the operation (29 patients; blockade group) or epidural saline (4-7 mL/h) and oral or intramuscular morphine (31 patients; control group). All patients had general anaesthesia for the amputation and were asked about stump and phantom pain after 1 week and then after 3, 6, and 12 months by two independent examiners. Study endpoints were rate of stump and phantom pain, intensity of stump and phantom pain, and consumption of opioids. FINDINGS: Two patients in each group were withdrawn before amputation. The groups were well matched in baseline characteristics. Median duration of preoperative saline treatment was 18.5 h (IQR 17-20). Median duration of preoperative epidural blockade in the blockade group was 18 h (15-20.3). The combined median duration of postoperative epidural pain treatment in both groups was 166 h (89.3-308.3). After 1 week, 14 (52%) patients in the blockade group and 15 (56%) in the control group had phantom pain (95% CI - 30.6 to 22.7, p = 0.9). The figures for blockade versus control group were: 14 (82%) vs ten (50%; 4.0 to 60.8, p = 0.09) at 3 months; 13 (81%) vs 11 (55%; -2.7 to 55.3, p = 0.2) at 6 months; and nine (75%) vs 11 (69%; -27.0 to 39.6, p = 1.0) at 12 months. Intensity of stump and phantom pain and consumption of opioids were similar in both groups at all four postoperative interviews. INTERPRETATION: Perioperative epidural blockade started a median of 18 h (15-20.3) before the amputation and continued into the postoperative period does not prevent phantom or stump pain.

Analgesia, Epidural↗
PubMed1995

Prosthetic usage in major upper extremity amputations.

Patterns of use of contemporary prostheses by 135 patients with major upper extremity amputations were evaluated by questionnaire. Eighty-four percent of the patients were male and 16% were female. Amputation levels represented were below elbow, 44%; above elbow, 40%; and shoulder disarticulations or forequarter amputations, 16%. The follow-up interval averaged 12 years (range, 1-67 years). One hundred and thirteen patients were fitted with either a myoelectric or body-powered prosthesis. The overall rejection rate was 38%. Thirty-nine of 42 in the below-elbow amputation group used the prosthesis and appeared to benefit the most. Eight of 141 in the wrist disarticulation group used the prosthesis: as did 9 of 21 in the above-elbow amputation group. In contrast, all bilateral amputees used their prostheses. Stiff shoulders and brachial plexus injury were both predictors for poor prosthetic usage.

Amputees↗
PubMed2002

Job satisfaction and health experience of people with a lower-limb amputation in comparison with healthy colleagues.

OBJECTIVES: To describe indicators of job dissatisfaction among amputee employees and to compare job satisfaction and health experience of working amputee employees with that of control subjects. DESIGN: A cross-sectional study, mailed questionnaire. SETTING: Patients were recruited by the orthopedic workshops of the Netherlands. PARTICIPANTS: One hundred forty-four patients who had an acquired unilateral major amputation of the lower limb at least 2 years before, were aged 18 to 60 years (mean age, 43y), and were living and working in the Netherlands. One hundred forty-four control subjects matched for age, gender, and type of job. INTERVENTIONS: Not applicable. MAIN OUTCOME MEASURES: Statistical analysis of responses to a questionnaire regarding patient characteristics and amputation-related factors, amputee patients' opinions about their work and the social atmosphere at work, and their general health (RAND 36-Item Health Survey [RAND-36]). RESULTS: People with an amputation had greater job satisfaction (70%) than did the able-bodied control group (54%). The wish for (better) modifications in the workplace and the presence of comorbidity were significantly related to job dissatisfaction in people with limb loss. Amputee employees were less often hindered by the failures of others and by fluctuations in temperature. People with limb loss showed a worse physical health experience than controls on the RAND-36. CONCLUSIONS: The vocational satisfaction of people with limb loss may be improved by better workplace modifications, depending on the functional capabilities of the person and the functional demands of the job; improvement may also be achieved by vocational rehabilitation programs, especially for those with an amputation in combination with other morbidity. Despite experiencing more health problems, the amputee group expressed greater job satisfaction than the able-bodied group, reflecting a great appreciation of job reintegration by people with a lower-limb amputation.

Adolescent↗
PubMed1994

Attention demands in balance recovery following lower limb amputation.

The attention demands in balance control after damage to the peripheral sensorimotor system were studied in 12 persons with a recent lower limb amputation. The interference of an arithmetic task with two postural tasks of different complexity (quiet standing and active weight shifting) was examined several times during their rehabilitation while the subjects stood on a force platform. Control data were obtained from healthy subjects. For both postural tasks, persons with amputation performed worse than controls. Quiet standing, a relatively simple task, revealed clear dual-task interference only in the amputation group. Evidence was found for a reduction in dual-task interference as rehabilitation progressed. In contrast, voluntary (feedback-controlled) weight shifting, a more complex task, revealed an equal amount of dual-task interference in persons with amputation and in controls, without changes in interference over the period of rehabilitation. The results indicate that attentional mechanisms may be involved in postural control, depending on both the novelty and complexity of the task. Moreover a reduction in attention demands of quiet standing may reflect a central adaptation of the postural organization to the peripheral sensorimotor impairments caused by lower limb amputation.

Journal Article↗
PubMed2006

Shoe adaptation after amputation of the II - V phalangeal bones of the foot.

In The Netherlands, about 50% of all amputations of the lower limb are toes and forefoot amputations. Traumata of toes and mid-foot are rare. Preservation of the foot is the primary goal for treatment. Crush injuries of the foot may be associated with prolonged morbidity. This case study presents an insole solution for the solitary first phalangeal bone after amputation of the phalangeal bones II - V. The normal adaptation for forefoot amputations is stiffening of the sole of the shoe and a rocker bar to improve the toe off phase with load reduction of the forefoot. Because the patient had to do excessive stair climbing during work another solution was chosen. As a foot orthosis, a metal soleplate was made in order to have free movement during loading and toe-off during walking. The soleplate gives safety and provides self-adjusting properties after toe off. This enables the shoe technician to make a shoe without a rocker bar or an extra stiff insole. The 0.5 mm custom-made spring-steel plate is also used as a protective in industrial safety shoes. To improve shoe adaptation more research and case reports have to be published in order to inform doctors and shoe technicians about everyday solutions to partial foot amputations.

Amputees↗
PubMed2000

Sexuality in persons with lower extremity amputations.

PURPOSE: There is a paucity of information regarding sexual functioning in persons with lower extremity amputations. The purpose of this study was to describe sexual and psychological functioning and health status in persons with lower extremity amputation. METHODS: Self-report surveys assessed sexual functioning (Derogatis Inventory), depression (Beck Depression Inventory, anxiety (State-Trait Anxiety Inventory), and health status (Health Status Questionnaire) in a convenience sample of 30 men with lower extremity amputations. Mean age of the participants was 57 years (range 32-79). Mean duration since amputation was 23 months (range 3-634 months). Twenty one subjects (70%) had trans-tibial and seven subjects (23%) had trans-femoral amputations. RESULTS: A majority of subjects were experiencing problems in several domains of sexual functioning. Fifty three percent (n = 16) of the subjects were engaged in sexual intercourse or oral sex at least once a month. Twenty seven percent (n = 8) were masturbating at least once a month. Nineteen subjects (63%) reported orgasmic problems and 67% were experiencing erectile difficulties. Despite these problems, interest in sex was high in over 90% of the subjects. There was no evidence of increased prevalence of depression or anxiety in these subjects when compared to other outpatient adult populations. CONCLUSIONS: Sexual problems were common in the subjects studied. Despite these problems, interest in sex remained high. Few investigations have been directed toward identifying the psychological and social factors that may contribute to these problems and more research with a larger population is needed in this area.

Adaptation, Psychological↗
PubMed2001

Use and satisfaction with prosthetic devices among persons with trauma-related amputations: a long-term outcome study.

OBJECTIVE: To document and examine the use, satisfaction, and problems with prosthetic devices among persons who suffered a trauma-related lower limb amputation. DESIGN: Abstracted medical records and follow-up interview data were collected for a retrospective cohort of persons with a lower limb trauma-related amputation who received their acute care at the University of Maryland R. Adams Cowley Shock Trauma Center, Baltimore, MD, between 1984 and 1994. Patients with spinal cord injury, traumatic brain injury, or only toe amputations were excluded. RESULTS: There were 146 patients identified. Of those, 9% died during the acute admission and 3.5% died after discharge. Seventy-eight amputees were available for interview (68% response rate). The majority of those interviewed were male (87%), and two-thirds had undergone amputation before age 40 yr. Nearly 95% had a prosthesis and wore it an average of 80 hr (SD = 33) per week. Despite high use, only 43% reported being satisfied with the comfort of their prosthesis. About one-quarter of all users reported problems with wounds, skin irritation, or pain. Traumatic amputees used an average of four prostheses since injury, about one new prosthesis every 2 yr. Statistical analyses revealed that males reported higher prosthetic use (P < 0.01). Higher Injury Severity Score negatively impacted on prosthetic use (P < 0.01). Phantom pain negatively influenced reported satisfaction with the prosthesis (P < 0.03) CONCLUSIONS: Although almost all persons living with trauma-related amputations use prosthetic devices, the majority are not satisfied with prosthetic comfort. Phantom pain and residual limb skin problems are also common afflictions in this population.

Adult↗
PubMed1984

Survival factors in replantation and revascularization of the amputated thumb--10 years experience.

An unabridged series of 73 thumb amputations subjected to replantation or revascularization surgery in the years 1971 to 1980 has been examined in detail as a combined prospective and retrospective study to determine the factors playing a role in survival and failure. The causes of failure and complications are demonstrated. The overall failure rate was 27%. The factors influencing the outcome were: the injury--mechanical type and degree of amputation; the patient--age and amputation level; and the surgeon--frequency of utilization of vein grafts. The highest failure was seen in the complete amputation with avulsion/diffuse crush injury group (63%). Incomplete amputations had the lowest failure rate, particularly if the injury type was guillotine/local crush and at a level proximal to the metacarpophalangeal joint. Patients aged 11 to 20 years had a low failure rate (18%) whereas children under 5 years had a high failure rate (40%). Arterial thrombosis was the most frequent complication and cause of failure. The surgeon could modify the result by frequent use of vein grafts for arterial reconstruction and by reoperation for thrombotic complication. Five thumbs failed to revascularize at the primary operation and were removed at this primary operation.

Adolescent↗
PubMed2002

Through-the-knee amputation: an improved technique.

Through-the-knee amputation (TKA) is an excellent lower extremity treatment for the ischemic extremity when revascularization is not feasible and a prosthesis is not practical. Over the past 8 years 185 major amputations have been performed at our hospital of which 63 were of the TKA type. In 61 of these an improved technique was used that resulted in nonischemic, strong, and aesthetic stumps with 100 per cent primary healing. Our technique consists of removing the distal 2 cm of the femoral head with the two condyles and allowing the patella to ankylose to the new distal femoral end. In comparison with the other major amputations the TKA with this technique had significant advantages over the above-knee amputation and often was found to be superior to the below-knee amputation especially when rehabilitative ambulation with a prosthesis was not possible.

Aged↗
PubMed1988

The immediate postoperative prosthesis (IPOP) in ischemia and septic amputations.

A retrospective analysis of the medical records of 17 consecutive patients undergoing lower extremity amputation and Immediate Postoperative Prosthesis (IPOP) placement for infectious complications of unreconstructable arterial insufficiency was performed. Significant soft tissue infection was present in 13 patients and osteomyelitis in four. The mean patient age was 59.4 years and 13 of 17 patients were diabetic. Fourteen patients underwent below knee and three underwent above knee amputations. Seven patients had undergone previous arterial reconstruction. Thirteen patients had previous ipsilateral amputations, five of which were open guillotine amputations performed between 3 and 7 days prior to definitive surgery. Four individuals (24%) required early removal of the IPOP, two due to patient noncompliance and two due to stump healing complications. Thirteen patients (76%) were successfully treated with IPOP and went on to achieve independent gait within 3 weeks of their definitive amputation.

Adult↗
PubMed1981

Some social and sexual problems experienced by Nigerians with limb amputation.

The socio-sexual dysfunctions associated with amputation were studied among a group of 100 Nigerians with limb amputations. The mean age was 30 years. Road traffic accidents and war-related injuries constituted 70% of cases. Decrease in social interaction as the result of amputation was reported by 20%, 13% of the married males admitted a change in sexual life and activities after the amputation; 24% of those studies had some form of sexual problems. Nigerians with amputation experience definite social and sexual problems.

Adult↗
PubMed2005

Amputation level viability in critical limb ischaemia: setting new standards.

We have previously demonstrated the successful use of skin oxygen saturation (SO2) measurements to predict the healing viability in lower limb amputations for critical limb ischaemia. The measurements are quick and easy to perform, but the instrument that has been used to date is now obsolete and a new, lightweight, portable instrument has recently been introduced. However, fundamental differences between the two instruments could influence the criteria used for determining amputation level viability. The purpose of this study was to compare the in vivo measurements using the two instruments in order to validate amputation level viability criteria using the RM200. Skin SO2 measurements were carried out on critically ischaemic lower limbs of patients, and on the forearms of normal volunteers during before, during and after a 5 minute period of tourniquet ischaemia. A linear correlation (r2 = 0.91) was found between the values obtained from the two instruments within the range of interest (0 to 40% SO2). Differences between the instruments lay within 1 standard deviation of the mean, demonstrating a high degree of agreement between the two methods. The RM200 is thus an acceptable replacement for the MCPD instrument for amputation level viability assessments.

Amputation, Surgical↗
PubMed2001

[Heterotopic replantation after bilateral lower leg amputation].

INTRODUCTION: Replantation is an established procedure in reconstructive surgery. In a bilateral lower leg amputation attempts should be made to rescue at least one extremity, if the patients' vital conditions are stable. PATIENT AND METHOD: We report on a patient who has suffered a bilateral lower leg amputation. Due to the complex injuries the left leg was heterotopically (cross-over) replanted to the right leg. At the left leg an above knee stump was created. In a second operation a soft tissue defect at the replanted extremity was covered by a free microvascular latissimus dorsi muscle flap. In addition, the tibial nerve was reconstructed. Thirteen months later the patient is able to walk with a prosthesis for his left leg and complete weight bearing of the replanted extremity. DISCUSSION: Indication for replantation depends on accompanying injuries and vital functions of the patient. Compared to a simple amputation a lower leg replantation prolongs hospital stay, delays mobilisation of the patient, and increases the necessary secondary procedures. However, after replantation functional outcome is mostly better than with prosthetic fitting, especially if reconstruction of sensation in the weight-bearing area is successful. Thus, in a bilateral amputation movement and stability, as well as quality of life, are improved by a replanted extremity.

Amputation Stumps↗
PubMed1977

Below-knee amputation: a modern approach.

Immediate and long-term results of 113 below-knee amputations in 103 patients are presented to justify a comprehensive program of management that includes an objective method for determining amputation level with xenon 133 clearance, precise surgical technic, immediate postoperative prosthesis, and an aggressive program of rehabilitaion. Prediction of healing of the last 30 below-knee amputations was 100% successful, showing the value of 133Xe clearance for determination of amputation level. Zero per cent thirty-day mortality and 100% prosthetic rehabilitation of patients on below-knee prostheses justifies the use of immediate postoperative prosthesis. Long-term follow-up of our patients demonstrates that the five year survival rate of diabetic patients is poor (39%) compared with the nondiabetic amputee (75%) who approached the survival of the normal, age-adjusted male population (85%). The fact that 75% of patients were alive after five years and were still independently ambulatory on their prostheses is final testimony to the value of the program.

Adult↗
PubMed1999

Healing of open stump wounds after vascular below-knee amputation: plaster cast socket with silicone sleeve versus elastic compression.

OBJECTIVE: To assess the effect of a plaster cast socket on the healing of open wounds and on temporary prosthesis fitting after below-knee amputation because of arterial occlusive disease. DESIGN: Randomized controlled trial. SETTING: Rehabilitation center, university hospital. PATIENTS: All included patients had undergone recent (in the previous 3 months) below-knee amputation because of arterial disease and initially had an open stump. Patients were randomly assigned to two groups of 28 subjects each. The sizes of the amputation scars were 8 to 24 cm2. Ischemia of the stump was eliminated as a probable cause of delayed wound healing by the inclusion criterion of transcutaneous oxygen tension (TcPO2) of >35 mmHg. The average age in group I (the experimental group) was 65.2 +/- 12.4 (SD) years and in group II (the control group) 66.8 +/- 10.8 years (not significant). INTERVENTION: A plaster cast (supracondylar-type) socket was fitted on the stumps of group I patients, interposed with a silicone sleeve. The patients were gradually trained to wear this cast for up to 5 hours a day. They were provided with elastic compression bandages for the remainder of the time. Patients in group II wore elastic compression bandages, which were only removed for dressing changes. MAIN OUTCOME MEASURES: Time required for stump healing, length of time between amputation and ability to walk wearing a contact socket, and length of hospital stay. RESULTS: Group I had a quicker average healing time (71.2 +/- 31.7 [SD] days compared to the control group's 96.8 +/- 54.9 days) and a shorter average length of hospital stay (99.8 +/- 22.4 days compared to the control group's 129.9 +/- 48.3 days). CONCLUSION: Use of a plaster cast socket leads to more rapid healing of the open stump and to a shorter hospitalization. If there is no stump ischemia, this plaster cast technique is safe.

Aged↗
PubMed2001

Orthotic and prosthetic devices in partial foot amputations.

With advanced surgical techniques and orthotic, as well as prosthetic devices, partial foot amputations have become a viable alternative. Orthotics can help restore stability, maintain support, and protect function of the residual limb. The authors discuss orthotic and prosthetic management of patients who have undergone toe amputations; ray amputations; transmetatarsal, Lisfranc-, or Chopart-level amputations.

Amputation, Surgical↗