Limb Deficiency and Prosthetic Management. 2. Aging With Limb Loss

2.1 Educational Activity: To describe the anticipated rehabilitation and prosthetic needs of a 14-year-old girl who sustains a traumatic transfemoral amputation 

IN THE PEDIATRIC POPULATION, congenital limb loss is reported to outnumber acquired limb loss by a 2:1 ratio,1 with 75% of pediatric acquired amputations being caused by trauma and 25% caused by neoplasm or other disease.2 There is a 2:1 male-to-female ratio of acquired amputation in the pediatric age group.1 Sixty percent of pediatric acquired amputations involve the lower limb, with transtibial being the most common level of limb loss. In order of incidence, trans-tibial is followed by transfemoral, transradial, and ankle disarticulation levels of limb loss.2 The most common etiologies of pediatric traumatic amputations in the United States are lawnmowers,1 farming equipment, and power tools, followed by vehicular collisions, gunshot wounds, explosions, railroad injuries, household accidents, burns, and electric injuries.2 In children under the age of 10 years, power lawnmower injury is the most common cause of amputation.2

Immediate postoperative management of the pediatric patient includes control of pain, edema, and infection; promotion of healing; and prevention of deconditioning, muscle atrophy, and joint contracture. Immediate postsurgical fitting of lower-limb amputations is not recommended in young children because of the higher potential for wound dehiscence from nonadherence to weight-bearing restrictions.2 However, an adolescent, like an adult, may benefit from immediate or early postoperative fitting with a temporary prosthesis.3 Prosthetic fitting should be delayed if the residual limb develops wound infection or skin breakdown. It may also be deferred if the residual limb requires secondary closure, repeated débridement, or skin grafting.3

Appearance of the prosthetic device may be a primary concern for this 14-year-old girl. The most commonly prescribed socket is the ischial containment design. It is reportedly more functional for most active people with transfemoral amputations. Use of a flexible socket design will also improve comfort and appearance. Initial use of an elastomeric liner with interlocking pin will allow the prosthesis to be suspended without the encumbrance of belts or straps. Full suction suspension should be considered when residual limb size and shape have stabilized. There are a wide range of prosthetic components to choose from for patients with transfemoral amputations. Variables to be considered in selecting components should include each patient’s anticipated activity level; preamputation vocational and avocational activities and interests; anticipated exposure of the device to moisture, dust, and repetitive stresses; body morphology; and access to prosthetic services for adjustments and repairs. Insurance coverage or other financial resources must be considered when prescribing a prosthesis, particularly for those patients with financial constraints. The characteristics, indications, advantages, and disadvantages of the various types of prosthetic components for transfemoral amputation are outlined in the 2001 Study Guide.4

This patient will benefit from a knee unit that allows for variable cadences and will provide stance stability during initial gait training. Options may include a simple hydraulic knee, a simple pneumatic knee, or a microprocessor-controlled hydraulic or pneumatic knee unit. Considerations regarding the foot and ankle components should include the ability to accommodate uneven terrain, energy storage, and weight of the device. Options include a dynamic response or multiaxial foot. People who consistently walk on uneven terrain may prefer the multiaxial foot, whereas a track athlete may prefer the stability of a dynamic response foot. Ideally, the patient will have the opportunity to choose among cosmetic finishes. A reasonable initial prosthetic prescription for this patient would have 4 components: (1) a flexible, ischial-containment socket; (2) a thin elastomeric liner with interlocking pin suspension; (3) a microprocessor-controlled hydraulic knee; and (4) a dynamic response foot.

Continuation of preamputation interests and activities should be considered during prosthetic prescription. After the patient becomes proficient with the initial prosthesis, consideration should be given to prescription of 1 or more special use devices such as a swim/shower leg or a prosthesis for specific sports activities (eg, one with a tibial rotation component for golfing). The limitations of the microprocessor knee, including intolerance of dust or moisture, and its increased requirement for maintenance and repair should be carefully considered and communicated to the patient. Sports and recreational activities for people with limb deficiencies were discussed in a previous Study Guide.5

An adolescent will typically require assessment and possible adjustment of prosthetic fit and alignment every 3 to 4 months and replacement of prosthetic components approximately every 3 years.2 Fitting the initial socket with a thicker elastomeric liner may increase the life of the socket. Instead of remolding the socket as growth occurs, the thickness of the liner can be decreased. Replacing the pylons can lengthen a prosthesis that otherwise still fits and functions. Components such as knee and foot-ankle units can be incorporated into new prosthetic devices as the child grows or activity needs change.

Loss of the knee joint, as in this patient, will result in approximately a 68% increase in total energy consumption per unit distance. To compensate for this increased energy demand, walking speed is proportionally reduced to achieve a rate of expenditure comparable to that of an unimpaired gait pattern.6 Maintaining physical activity is extremely important, not only to prevent weight gain and deconditioning but also to promote psychologic and emotional health.3 This patient is expected to ambulate without an assistive device and to become independent in prosthetic management, and she should be taught falling techniques that prevent injuries.7 A person with unilateral lower-limb loss is generally capable of driving a vehicle with automatic transmission that is adapted so that the intact limb (not the prosthesis) is used to operate the foot pedals.8 Vocational planning should consider physical limitations such as decreased standing tolerance, reduced ability to climb or descend stairs, and impaired balance. Literature regarding vocational satisfaction of people with limb loss is limited. Schoppen et al9 found that dissatisfaction among people with lower-limb loss correlated significantly with higher comorbidity, lower mobility level, and the desire for more modifications in the work place. However, in this same study, people with lower-limb loss were, overall, more satisfied with their jobs than their coworkers without limb loss.

Psychosocially, at 14 years of age, this female patient is developing emotional independence from her family. She is testing limits and autonomy and is deciding her future orientation and plans. Infants, toddlers, and younger children would be more dependent on family, both physically and emotionally. Although peer relations and acceptance are already important in middle (6–12y) childhood, this adolescent most likely will show an elevated degree of self-consciousness and be very concerned regarding her self-image in relation to her peers. The need to fit in with her peers assumes a high, if not the highest, priority at this stage. She will have to integrate her limb loss and the prosthetic device into her identity. She may cope with her loss with denial, hyperactivity, and/or withdrawal. To work effectively with this young woman, the rehabilitation team must be aware of and respect her individuality, privacy needs, and confidentiality. They must be open to discussion of her individual needs and concerns when the opportunity presents itself and must encourage or even require that she be involved in decisions about treatment and choice of prosthetic device(s), recognizing the priority of appearance as well as function.10 Reactions of family and peers and the circumstances of the injury leading to the amputation must be considered. They will significantly affect the emotional adjustment and rehabilitation outcome of any child sustaining limb loss. Support for re-entry into her social milieu may include education of her peers regarding the abilities and expectations of people with limb amputation.

It should not be assumed that at age 14 the patient has already asked for and received adequate information about sexuality, sexual activity, and contraception. A survey of women with physical disabilities (primarily neurologic impairments) showed that adolescents who sustained disabling injury after the age of 14 years were less likely to request or be offered information regarding contraception. When information was received, women with onset of disability after the age of 14 years reported feeling that the information provided was neither adequate nor specific to their disability.11

A transfemoral amputation will not affect the patient’s ability to conceive and bear children. There is limited literature regarding pregnancy in women with transfemoral amputation; however, issues such as edema and change in body morphology during pregnancy may require prosthetic alterations or adjustments or even use of alternative mobility strategies (crutches, wheelchair). People with amputation at the hemipelvectomy level have been reported to successfully carry a pregnancy to term, but may require a custom support sling during pregnancy to replace the removed pelvic floor muscles and pelvis.12 Labor and delivery should not present any unique problems for a person with unilateral amputation, although there is a single case report of phantom limb pain during labor in a woman with transfemoral amputation.13 The vast majority of young transfemoral amputees will ambulate without assistive devices, so their ability to care for an infant will not be affected in this regard. However, childcare during the night, when the prosthesis is removed, may present challenges. A wheelchair to allow mobility while carrying an infant in the lap can be helpful.

The Amputation Coalition of America provides educational resources for children, adolescents, and their parents as well as for adults concerned about amputations. There are also multiple links to peer groups and other organizations. The web address is http://www.amputee-coalition.org.

2.2 Educational Activity: To discuss the rehabilitation management of this patient when she is 55 years old and presents with contralateral knee and hip pain interfering with mobility 

There is evidence that physiologic changes occur with the normal aging process. Lean body mass usually decreases because of muscle atrophy and increased adiposity. There is a loss of bone density and changes occur in cardiac and renal function, hormonal regulation, and cerebral function. Changes in gait may include decrease in trunk and associated movement caused by degenerative arthritis, contractures, or neurologic impairments. Changes in step length, cadence, excursion of the leg during swing, swing-to-stance ratio, and maneuvers to increase the base of support may be associated with limitations of joint range of motion at the hips or knees, instability associated with neurologic disorders, limited vision, or fear of falling. Increased vertical displacement of the center of mass may be associated with muscle weakness resulting in knee and hip instability. These changes may result in a slower gait and increased energy cost of ambulation. Chronic diseases such as arthritis, impaired hearing and/or vision, diabetes, heart disease, and cognitive disorders become more common with aging and may also negatively affect functional mobility. People who have sustained limb loss in childhood or young adulthood experience aging effects superimposed on their existing impairments and disabilities.14 New impairments may be the consequence of prosthetic-related problems, new disease processes, or both. Onset of symptoms after a change in the design or alignment of the prosthesis may suggest gait alteration leading to new stresses on the contralateral limb. On the other hand, an insidious onset of symptoms without change in activities or prosthetic device may suggest that the primary problem lies in the symptomatic limb. Musculoskeletal disorders, such as osteoarthritis, tendinitis, bursitis, or occult fracture, usually present with localized findings. Symptoms that resolve quickly with rest or sitting down may suggest vascular or neurogenic claudication. Specific myotomal weakness or dermatomal sensory impairment with or without back pain may suggest a radiculopathy. Once a differential diagnosis is developed, appropriate diagnostic testing can be planned and treatment initiated.

In this case, the likely diagnosis is degenerative joint disease affecting the hip and/or knee. An increased prevalence of accelerated degenerative joint disease has been reported in people with transtibial or transfemoral amputations.15, 16, 17, 18 Studies regarding management of osteoarthritis either in the remaining joints of the amputated limb or of the intact limb are sparse. Management should include careful assessment of the prosthetic limb and adjustment to minimize gait deviation and to unload the affected joints. Management may require an interdisciplinary approach and should include the following goals: improve or maintain joint range of motion; promote muscle strengthening and conditioning; minimize joint stress by the use of assistive or mobility devices; and address pain control.

Weight control is an important but frequently neglected issue in the management of osteoarthritis of weight-bearing joints. There is some conflict in the literature regarding a relation between traumatic amputation and obesity, but reports using U.S. populations show an increased incidence of obesity and increase in body fat in people sustaining lower limb loss. Rose et al19 reported that a population of 19 Vietnam veterans with bilateral above-knee amputations compared with a control group with unilateral below-elbow amputation had significantly higher body weight and percentage of body fat.

Ryder20 cites data indicating a clearly significant increase in weight in people with lower-limb amputation, with a greater prevalence the more proximal the amputation. Joint replacement is commonly performed in people without limb loss for advanced osteoarthritis that is nonresponsive to less invasive measures. The literature regarding joint replacement in people with limb amputation is limited to case reports that indicate success with knee arthroplasty on both the amputated and intact sides.21

2.3 Educational Activity: To discuss the management of a 65-year-old man with previous transtibial amputation who undergoes transfemoral amputation on the contralateral side secondary to nonhealing of a diabetic foot ulcer 

The comorbidities associated with diabetes mellitus are discussed in section 4.2 of this Study Guide. In assessing the rehabilitation needs and potential of this patient, the following factors should be considered: limited activity tolerance because of underlying atherosclerotic heart disease (with symptomatic or silent ischemia); peripheral vascular disease and diabetic nephropathy; unstable residual limb volume because of fluctuating weight, renal disease or congestive heart failure; impaired cognition or other neurologic deficits because of cerebrovascular disease; sensorimotor deficits caused by peripheral nerve dysfunction; and visual impairment as a result of diabetic retinopathy or other ophthalmic disorders.

The literature indicates that people with lower-limb amputations are at increased risk of cardiovascular disorders.18, 19, 22, 23 A transfemoral amputation caused by vascular disease is reported to increase the metabolic cost of ambulation approximately 100% per unit of distance.6 The combination of a transtibial and transfemoral amputation is expected to have an additive effect with respect to energy cost and therefore will severely limit the potential for functional ambulation.

Studies of the prosthetic outcome of major lower-limb loss are difficult to interpret and compare. There are few prospective studies where populations and the surgical and rehabilitative management of specific populations are well defined. Many outcome studies are limited only to patients who were referred for rehabilitation.24 A reported predictor of successful prosthetic outcome in people with 1 transfemoral and 1 trans-tibial amputation is prior successful ambulation with a transfemoral prosthesis.16

If prosthetic use and ambulation were limited by angina, exertional dyspnea, joint or spine pain, or other impairments before the transfemoral amputation, then functional ambulation with a second transfemoral prosthesis may not be a viable goal. Rehabilitation intervention will be directed toward alternative mobility and use of the transtibial prosthesis for transfers. This patient may not initially appreciate the challenges involved in using bilateral prostheses. Realistic goals should be established before considering prescription of a transfemoral prosthesis.25 Goals should focus on demonstration of adequate balance, upper- and lower-body muscle strength, joint range of motion, and aerobic capacity to meet the demands of using the prosthetic devices. Specific goals may include achieving independent transfer skills, manual wheelchair mobility and endurance, and arising and standing with upper-body support and partial weight bearing through the previously fitted prosthesis. Even with this approach, it may be difficult to determine if the patient will be able to ambulate functionally with the prostheses. In this case, fitting with a preparatory or temporary prosthesis may be appropriate.

A population study by Fletcher et al26 identified age more than 64 years, dementia, and transfemoral amputation as negative predictive factors for successful prosthetic fitting, whereas presence of a family member at home and marriage were reported as positive univariate predictors. In this study, only 14.5% of subjects undergoing unilateral transfemoral amputation caused by vascular disease were successfully fitted with a permanent prosthesis. Of 6 subjects with transfemoral and transtibial amputations, only 1 was successfully fitted with prosthetic limbs.

Physiatric evaluation and intervention is valuable even for patients who are identified as inappropriate for prosthetic fitting. The newly amputated residual limb should be monitored for wound healing, management of edema, and pain control. Early pain management may prevent the development of chronic pain syndromes.27, 28 If the patient is nonambulatory, he may be able to use his transtibial prosthesis for transfers. He may need initial evaluation for an appropriate wheelchair or modifications to an existing wheelchair to prevent skin breakdown and maintain proper sitting posture. He may require modifications to his home to make it wheelchair accessible. He may require other adaptive equipment such as a hospital bed, bathroom equipment (eg, grab-bars, raised toilet seat), and other durable medical equipment. If the patient cannot achieve independence, caregivers will need training and support if the patient is to successfully return to his home and community.

2.4 Educational Activity: To discuss the anticipated long-term rehabilitation needs and vocational implications for a 27-year-old male carpenter with a traumatic transhumeral amputation 

Dillingham et al29 reported that between 1988 and 1996, upper-limb amputations accounted for only 3% of all limb amputations but represented 68.6% of all traumatic amputations. Vascular disease and tumor accounted for 3% and 23% of all upper-limb amputations, respectively. Nearly three quarters of the traumatic upper-limb amputations were at the level of the finger (51.2%) or thumb (12.4%), whereas 3% were at the transradial level and 2% were at the transhumeral level. The remaining traumatic upper-limb losses included hand, wrist, through-elbow, shoulder, or forequarter amputations. There were 0.3% bilateral traumatic upper-limb amputations. Dillingham29 also reported that men were at higher risk for traumatic limb loss (upper vs lower limb not specified) in all age groups. Incidence of traumatic limb loss (upper vs lower limb not specified) increased steadily with age, reaching its highest level in those aged 85 years and older.

Upper-limb prosthetic components and prescriptions were previously discussed in the 2001 Acquired Limb Deficiencies Study Guide.4 Advances in prosthetic devices will be discussed in the focused review section of this Study Guide. Specialized prosthetic devices may facilitate the performance of a wide variety of bimanual activities. Childcare may require the use of a padded or soft terminal device for safety and comfort. Specific vocational or avocational activities may require task-specific prosthetics components. A wide range of task-specific terminal devices are available for activities such as for bowling, golfing, and fishing. Hooks with custom-designed curves and pincers, which are useful for people engaged in farming tasks, carrying heavy loads, and so forth, are also available. People with upper-limb amputation may want 1 prosthetic device for social activities and a second prosthesis for functional or vocational activities. Prosthetic prescription must take into account all aspects of the patient’s life and it is unlikely that a single device will fulfill all needs.30

Return to work as a carpenter may be possible but would most likely require significant accommodations and specialized prosthetic devices. The loss of the elbow joint will further complicate accommodation and the patient may find it more practical to retrain in an area not requiring as much bimanual dexterity. If he does return to carpentry or similar work, he would benefit from having more than 1 prosthetic device—a “work” arm and a “leisure or social” arm. The “work” arm might have a laminated finish to withstand trauma and heavy use in the work place. If the work environment is dusty or if there is risk of exposure to moisture, externally powered components may be contraindicated. A rotational wrist unit with flexion capability, a quick disconnect unit and multiple specialized terminal devices may be required in the workplace. On the other hand, in social situations the patient most likely will prefer a more cosmetically appealing device. He may wish to exclude the relatively heavy but adaptable wrist unit and opt for a simpler constant-friction–type of device with a cosmetic hand. Pinzur et al31 reported that, in a series of 19 people with traumatic upper-limb amputation, 15 were employed at the time of the amputation. At an average of 52 months after amputation, 5 had returned to the same or similar job, 5 were employed in a job that required less manual dexterity, 1 was employed in a job that seemed to require more bimanual dexterity, and 4 were unemployed.31

Acceptance and use of upper-limb prosthetic devices are uniformly reported as less than of lower-limb prosthetic devices. Also, the more proximal the amputation, the less likely a prosthetic device will be used. Introduction of the prosthetic device as soon as is feasible after amputation is believed to facilitate prosthetic acceptance and use, particularly in a patient with unilateral upper-limb amputation.32 Pinzur31 surveyed 19 people with traumatic upper-limb amputation, most of whom were fitted with temporary, body-powered prostheses within 30 days of amputation. Functional prosthetic use was defined as wearing and using the prosthetic device at least 8 hours a day. At an average of 52 months after amputation, 9 of 10 people with amputation at the transradial level, 5 of 6 with amputation at the transhumeral level, and 1 of 2 with amputation at the shoulder disarticulation level reported themselves to be functional prosthetic users. One person with a shoulder disarticulation was lost to follow up.

Even people with upper-limb amputations who report wearing a prosthetic device regularly may perform many activities “single handed” because it is more efficient or convenient. This may raise a concern that overuse and degenerative syndromes in the intact upper limb may lead to future increased impairment and disability. Jones and Davidson33 reported that 50% of people with upper-limb amputations had problems with the intact limb. Problems included an array of overuse syndromes such as epicondylitis, shoulder impingement, tenosynovitis, osteoarthritis, carpal tunnel syndrome, trigger finger, and other nonspecific problems. Only 3 of the 26 reported injury to the intact arm from the accident resulting in the amputation. Data showed a trend toward intact arm pain being more prevalent the more proximal the amputation.33