Lower limb amputation. Part 1: Amputation methods--a 10 year literature review

An insight into Transfemoral Prostheses: Materials, modelling, simulation, fabrication, testing, clinical evaluation and performance perspectives

INTRODUCTION

A Transfemoral prosthesis restores any limb amputated above the knee. Designing and developing a transfemoral prosthesis that is consistent with human performance is a tough task. While prosthetic components are widely available in the market, ongoing research is being conducted to develop parts that would restore the lost capability, taking into account numerous social, economic and technological considerations.

AREAS COVERED

The present paper provides a comprehensive review about the mechanical aspects and performance of transfemoral prosthesis in recent years based on the research findings on materials, manufacturing methods and evaluations for suitability of the prostheses. The fundamental terminologies as well as technical advancements are covered in order to impart a better knowledge in the area of Lower Limb prostheses. This review also provides a concise description on the role of computers, advanced software packages, sensors and other hardware components for the design, fabrication and testing of transfemoral prosthetic devices in the current environment.

EXPERT OPINION

The current state of lower limb prostheses and future research opportunities are summarised to address upcoming challenges. Based on survey of various research works, adapting modern technology may aid in the development of functional and cost-efficient prosthetic components with superior safety, comfort and quality.

Through-knee versus above-knee amputation for vascular and non-vascular major lower limb amputations

BACKGROUND

Diabetes and vascular disease are the leading causes of lower limb amputation. Currently, 463 million adults are living with diabetes, and 202 million with peripheral vascular disease, worldwide. When a lower limb amputation is considered, preservation of the knee in a below-knee amputation allows for superior functional recovery when compared with amputation at a higher level. When a below-knee amputation is not feasible, the most common alternative performed is an above-knee amputation. Another possible option, which is less commonly performed, is a through-knee amputation which may offer some potential functional benefits over an above-knee amputation.

OBJECTIVES

To assess the effects of through-knee amputation compared to above-knee amputation on clinical and rehabilitation outcomes and complication rates for all patients undergoing vascular and non-vascular major lower limb amputation.

SEARCH METHODS

The Cochrane Vascular Information Specialist searched the Cochrane Vascular Specialised Register, CENTRAL, MEDLINE, Embase, and CINAHL databases; the World Health Organization International Clinical Trials Registry Platform; and the ClinicalTrials.gov trials register to 17 February 2021. We undertook reference checking, citation searching, and contact with study authors to identify additional studies.

SELECTION CRITERIA

Published and unpublished randomised controlled trials (RCTs) comparing through-knee amputation and above-knee amputation were eligible for inclusion in this study. Primary outcomes were uncomplicated primary wound healing and prosthetic limb fitting. Secondary outcomes included time taken to achieve independent mobility with a prosthesis, health-related quality of life, walking speed, pain, and 30-day survival.

DATA COLLECTION AND ANALYSIS

Two review authors independently reviewed all records identified by the search. Data collection and extraction were planned in line with recommendations outlined in the Cochrane Handbook for Systematic Reviews of Interventions. We planned to assess the certainty of evidence using the GRADE approach.

MAIN RESULTS

We did not identify RCTs that met the inclusion criteria for this review.

AUTHORS' CONCLUSIONS

No RCTs have been conducted to determine comparative clinical or rehabilitation outcomes of through-knee amputation and above-knee amputation, or complication rates. It is unknown whether either of these approaches offers improved outcomes for patients. RCTs are needed to guide practice and to ensure the best outcomes for this patient group.

Outcomes of knee disarticulation and the influence of surgical techniques in dysvascular patients: A systematic review

BACKGROUND

Dysvascularity is the main cause of lower limb amputations in Scotland, and there is an insignificant proportion (1.7%) of knee disarticulations, despite the benefits of amputation.

OBJECTIVES

The outcomes of knee disarticulation and its associated surgical techniques will be evaluated based on healing, reamputations, functional outcomes, prosthetic ambulation and gait biomechanics to determine whether a greater rate of knee disarticulations can be justified among dysvascular patients.

STUDY DESIGN

Systematic review.

METHODS

Key electronic databases were searched for the relevant literature based on a pre-specified eligibility criterion.

RESULTS

The 17 articles included in this review were appraised for their quality, and key findings are extracted.

CONCLUSION

Healing rates are favourable, but there is a need for appropriate amputation level selection to prevent reamputations. Knee disarticulation patients have better maintenance of independent living status than transfemoral patients, but overall prosthetic ambulation rates are inconsistent. In terms of gait biomechanics of knee disarticulation, there are some positive indications, but the evidence is insubstantial. A stronger body of evidence is required in this subject field, and recommendations are made for future research - Scottish Intercollegiate Guidelines Network Grade of Recommendation: C.

CLINICAL RELEVANCE

This review aims to inform the multidisciplinary teams involved in the rehabilitation of dysvascular amputees about evidence-based outcomes following knee disarticulation. This knowledge will be beneficial when formulating treatment pathways for this vulnerable population group.

Factors affecting outcome after traumatic limb amputation

BACKGROUND

Traumatic leg amputation commonly affects young, active people and leads to poor long-term outcomes. The aim of this review was to describe common causes of disability and highlight therapeutic interventions that may optimize outcome after traumatic leg amputation.

METHODS

A comprehensive search of MEDLINE, Embase and Cumulative Index to Nursing and Allied Health Literature databases was performed, using the terms 'leg injury', 'amputation' and 'outcome'. Articles reporting outcomes following traumatic leg amputation were included.

RESULTS

Studies demonstrated that pain, psychological illness, decreased physical and vocational function, and increased cardiovascular morbidity and mortality were common causes of disability after traumatic leg amputation. The evidence highlights that appropriate preoperative management and operative techniques, in conjunction with suitable rehabilitation and postoperative follow-up, can lead to improved treatment outcome and patient satisfaction.

CONCLUSION

Patients who undergo leg amputation after trauma are at risk of poor long-term physical and mental health. Clinicians involved in their care have many opportunities to improve their outcome using a variety of therapeutic variables. Copyright © 2011 British Journal of Surgery Society Ltd. Published by John Wiley & Sons, Ltd.

A novel technique for transtibial amputation in chronic occlusive arterial disease: Modified Burgess procedure

The aim of this study was to compare results of transtibial amputations performed using the Burgess or Modified Burgess techniques with those performed using the Bruckner technique. Transtibial amputation (TTA) was performed in 117 patients with Fontaine phase IV chronic arterial occlusion. Fifty-six patients with a mean age of 51.4 years were amputated by the Burgess technique between March 2000 and January 2003; and 61 patients with a mean age of 47.8 years were amputated by Modified Burgess technique between February 2003 and March 2006. In the Burgess technique, all muscles in the amputation region were preserved and the stump was closed by a long posterior flap; whereas the entire tibialis anterior muscle and part of the soleus muscle distal to the amputation level were removed in the modified Burgess procedure. Stump revision was performed in nine cases (17.3%) amputated by the Burgess technique due to necrosis at the incision site and drainage caused by the peroneal and tibialis anterior muscles; however, two cases (3.6%) of the modified Burgess procedure required stump revision. The prosthesis caused skin maceration at the lateral side of the stump in five cases (9.6%) operated with the Burgess technique and in eight cases (14.5%) operated with the modified Burgess procedure. After the rehabilitation period, 43 patients (82.6%) in the Burgess group were mobilized without crutches in an average of 162.5 days; on the other hand 51 patients (% 92.7) in the modified Burgess group were similarly mobilized in an average of 101.5 days. Our retrospective study showed that the modified Burgess technique, with its advantages and disadvantages forms an alternative to the Burgess and Bruckner techniques regarding TTAs.

Proximal major limb amputations--a retrospective analysis of 45 oncological cases

BACKGROUND

Proximal major limb amputations due to malignant tumors have become rare but are still a valuable treatment option in palliation and in some cases can even cure. The aim of this retrospective study was to analyse outcome in those patients, including the postoperative course, survival, pain, quality of life, and prosthesis usage.

METHODS

Data of 45 consecutive patients was acquired from patient's charts and contact to patients, and general practitioners. Patients with interscapulothoracic amputation (n = 14), shoulder disarticulation (n = 13), hemipelvectomy (n = 3) or hip disarticulation (n = 15) were included.

RESULTS

The rate of proximal major limb amputations in patients treated for sarcoma was 2.3% (37 out of 1597). Survival for all patients was 42.9% after one year and 12.7% after five years. Survival was significantly better in patients with complete tumor resections. Postoperative chemotherapy and radiation did not prolong survival. Eighteen percent of the patients with malignant disease developed local recurrence. In 44%, postoperative complications were observed. Different modalities of postoperative pain management and the site of the amputation had no significant influence on long-term pain assessment and quality of life. Eighty-seven percent suffered from phantom pain, 15.6% considered their quality of life worse than before the operation. Thirty-two percent of the patients who received a prosthesis used it regularly.

CONCLUSION

Proximal major limb amputations severely interfere with patients' body function and are the last, albeit valuable, option within the treatment concept of extremity malignancies or severe infections. Besides short survival, high complication rates, and postoperative pain, patients' quality of life can be improved for the time they have remaining.

CONCEPTS OF TRANSTIBIAL AMPUTATION: BURGESS TECHNIQUE VERSUS MODIFIED BRÜCKNER PROCEDURE

The technique of a long posterior myocutaneous flap described by Ernest M. Burgess in the late 1960s is one of the most frequent procedures for below-knee amputations worldwide. To account for some potential problems associated with this procedure in patients with occlusive arterial disease, Lutz Brückner developed a modified amputation technique for transtibial amputation in the 1980s. Although this new standardized procedure has been widely used in Germany, it is not well known outside central Europe, secondary to its lack of description in English published work. In this review article, we describe a comparison of the technical aspects of the Burgess procedure with the modified Brückner technique for transtibial amputations. In addition, the charts of 69 consecutive patients with end-stage occlusive arterial disease undergoing below-knee amputation by either of the two standardized procedures (Burgess, n = 29; Brückner, n = 40) were reviewed. The clinical results of the two procedures are reported and compared. Review of the German published work suggests that the two techniques for transtibial amputation in patients with occlusive arterial disease appear to have similar results. This is further supported by data from our own 10-year experience with 69 patients undergoing below-knee amputation by either of the two standardized procedures. This suggests that the Brückner technique is at least equivalent to the Burgess procedure with regard to the clinical outcome in patients with occlusive arterial disease. The potential advantages of the standardized modified Brückner procedure compared with the 'classical' Burgess technique for transtibial amputation remain to be assessed in prospective multicentre trials.

The geriatric amputee

There are special aspects of aging with an amputation and with being elderly at the time of an amputation. Older adults who have undergone amputation have many issues to contend with, including comorbidities that affect postoperative care and rehabilitation, general deconditioning and loss of mobility (especially if the onset of rehabilitation is delayed), and lack of social support upon returning to the community. These problems are compounded by a lack of knowledge about caring for the residual limb and prosthesis, maintenance of general health, and management of comorbid conditions. People who have sustained an amputation at an early age and who are ambulatory may find increasing difficulties as they age. Acquired chronic disease occurs more frequently as people age. These conditions can adversely affect function after amputation. Prosthetic designs may need modification because certain components may become more difficult to use. The prevention of a (second) amputation results in saving a limb and preserving self-image and independent function. Considering the emotional and economic cost of amputation and lifelong management of a prosthesis, it is worth the time and effort to practice preventive measures. Should amputation become necessary, careful patient assessment, compassionate management, and communication among the team members results in a more favorable outcome. Including the physiatrist early in the clinical course makes this process easier.

Limb salvage and amputation in survivors of pediatric lower-extremity bone tumors: what are the long-term implications?

The past four decades have seen tremendous progress in the treatment of pediatric and adolescent cancers. As a consequence, there are increasing numbers of adult childhood cancer survivors. This has prompted investigation into the long-term consequences of cancer treatments. One group that merits special study is the survivors of lower-extremity bone tumors. Their function and quality of life may depend in part on both the surgery and the age at which it was performed. Comparisons between studies are difficult because small numbers of patients and the use of varying research designs and methods have limited research in this area. The purpose of this article is to review the major surgical approaches to lower-limb bone tumors and their impact on pediatric patients. The results show that survival is equivalent between amputation and limb salvage. Complications occur more frequently in limb salvage. The long-term outcomes of those undergoing amputation and limb salvage have not been found to be substantially different in regard to quality of life. In conclusion, prospective long-term follow-up of pediatric patients with lower-limb tumors is needed to (1) determine in a uniform manner the long-term complications, quality of life, and functionality of this population and describe differences within this patient population based on age at diagnosis and surgical procedure, (2) identify areas of concern that are amenable to intervention, and (3) provide clinicians and future patients a better understanding of the surgical options.