Lower limb proximal amputation for a tumour: a retrospective study of 12 patients

Hip disarticulation and hemipelvectomy prostheses: A review of the literature

BACKGROUND

Although the global population of people with a hip disarticulation (HD) or hemipelvectomy (HP) amputation is small, the degree of disability is high, affecting function and independence. A comprehensive literature review is needed to examine the evidence for prostheses in these amputation levels.

METHOD

A scoping literature review was conducted to examine related research documents from 1950 to September 2020, found using Scopus, Web of Science, PubMed, and Google Scholar databases. Studies evaluated (retrospectively or prospectively) HD or HP prostheses and were written in English. Study design and protocol, research instrument, sample size, and outcome measures were reviewed.

RESULTS

In the past 70 years, 53 articles that evaluated HD or HP prostheses were published. Most research was conducted in the United States (24 articles) and Japan (nine articles). In 42 articles, authors prospectively evaluated the effects of prostheses in these amputation levels. On average, prospective studies had four (SD = 5) participants. Since 1950, only five prospective studies evaluated HD or HP prostheses with 10 or more participants. Moreover, sufficient information was often unavailable for research replication.

CONCLUSION

More evidence is needed regarding the effects of HD or HP prosthetic components (i.e. hip, knee, ankle, socket type, and suspension system) on gait, patient satisfaction, prosthetic use, interface pressure, and energy expenditure. Articles mostly have small sample sizes that reduce confidence in the reliability of their findings and limit generalizability. Future investigations are needed with vigorous methodology and larger sample sizes to provide strong statistical conclusions.

Functional capacity of elderly with lower-limb amputation after prosthesis rehabilitation: a longitudinal study

OBJECTIVES

Elderly amputees are a specific clientele because of the interaction of this disease with the ageing process. The objective of this study was to determine the impact of prosthesis rehabilitation on the functional capacity of elderly with lower-limb amputation (LLA) in short and long time.

MATERIALS AND METHODS

A quasi-experimental study was developed. The sample consisted of 29 elderly with LLA who finished the prosthesis rehabilitation programme. Gait capacity was evaluated by Functional Ambulation Classification Scale (FAC), ability to perform basic activities of daily living (ADL) was evaluated by Barthel Index (BI) and Pfeffer Questionnaire was used to evaluate the capacity to execute instrumental ADL. Statistical inference was done by t-test, t-student test and chi-squared test. The significance level was fixed at 5% (p < 0.05).

RESULTS

In the transtibial group (n = 15) no difference (p = 0.108) was found between BI score before amputation and after 3 months of follow up. The transfemoral group (n = 14) improved significantly (p = 0.045) the FAC before starting and after 3 months of discharge from ambulatory rehabilitation. Both groups increased the time of prosthesis use during the day after 3 months of follow up. However, no group has achieved FAC and Pfeffer Questionnaire pre-amputation performance.

CONCLUSION

Although elderly with LLA improved functional capacity after 3 months of a prosthesis rehabilitation programme, they did not achieve their pre-amputation functionality.Implications for rehabilitationLower-limb amputation causes a significant socioeconomic impact and decreases functional capacity, autonomy and quality of life. Elderly people with a lower-limb amputation impose a heavy burden on health resources, requiring extensive rehabilitation and long term care. The specific presentation of elderly persons with lower-limb amputation, with multiple physical, psychological, cognitive, and social comorbidities, imposes unique challenges to ongoing care. The potential bias from the inclusion of younger patients into a study with an elderly population with lower-limb amputation supports the need for independent investigation.In our study we verified that although elderly with transfemoral or transtibial amputation have improved their functional independence after lower-limb prosthesis rehabilitation, they could not achieve their functional capacity before amputation. This improvement especially occurred for the basic activities of daily living, however elderly patients with transfemoral amputations presented greater difficulty in improving functional capacity.These results support that being able to better select elderly by their mobility potential and environmental barriers, is an important goal for future research to aim toward those who will achieve and maintain prosthetic walking or those who could better focus on regaining nonprosthetic mobility.

Custom-made endoprostheses for the femoral amputation stump: an alternative to hip disarticulation in tumour surgery

Disarticulation of the hip in patients with high-grade tumours in the upper thigh results in significant morbidity. In patients with no disease of the proximal soft tissue a femoral stump may be preserved, leaving a fulcrum for movement and weight-bearing. We reviewed nine patients in whom the oncological decision would normally be to disarticulate, but who were treated by implantation of an endoprosthesis in order to create a functioning femoral stump. The surgery was undertaken for chondrosarcoma in four patients, pleomorphic sarcoma in three, osteosarcoma in one and fibrous dysplasia in one. At follow-up at a mean of 80 months (34 to 132), seven patients were alive and free from disease, one had died from lung metastases and another from a myocardial infarction. The mean functional outcome assessment was 50 (musculoskeletal tumor society), 50 and 60 (physical and mental Short-form 36 scores). Implantation of an endoprosthesis into the stump in carefully selected patients allows fitting of an above-knee prosthesis and improves wellbeing and the functional outcome.

Functional outcome of hip disarticulation and hemipelvectomy: a cross-sectional national descriptive study in the Netherlands

OBJECTIVE

To describe characteristics of hip disarticulation and hemipelvectomy amputees, to assess their level of activities, participation and experienced limitations in mobility and to describe the amputation-related problems.

DESIGN

A cross-sectional study.

SETTING

Patients were mainly recruited via orthopaedic workshops in the Netherlands.

SUBJECTS

Forty-six patients with an acquired unilateral hip disarticulation or hemipelvectomy at least one year post amputation.

MAIN OUTCOME MEASURES

Sickness Impact Profile 68 (SIP 68) to assess the level of activity and participation and the questionnaire Rising and Sitting Down, Walking and Climbing Stairs to assess perceived limitations in mobility.

RESULTS

The 46 patients (31 with hip disarticulation and 15 with hemipelvectomy) had a mean age of 55.8 years (SD 12.1). In 78% of cases the reason for amputation was a tumour. Mean SIP 68 was low, 10.5 (SD 6.9). Hip disarticulation amputees had significantly poorer emotional stability than the hemipelvectomy amputees (P = 0.04). All amputees experienced considerable limitations in their mobility according to the Rising and Sitting Down, Walking and Climbing Stairs scores.

CONCLUSIONS

Hip disarticulation and hemipelvectomy amputees have a relatively high level of activity and participation (SIP scores) but at the same time experience limitations in walking, rising and sitting down and climbing stairs.

Return to work after lower limb amputation

PURPOSE

To review the literature on return to work after lower limb amputation.

METHOD

A comprehensive review of literature on return to work after lower limb amputation was carried out, searching MEDLINE and PubMED.

RESULTS

Most authors found return-to-work rate to be about 66%. Between 22 and 67% of the subjects retained the same occupation, while the remainder had to change occupation. Post-amputation jobs were generally more complex with a requirement for a higher level of general educational development and were physically less demanding. The return to work depends on: general factors, such as age, gender and educational level; factors related to impairments and disabilities due to amputation (amputation level, multiple amputations, comorbidity, reason for amputation, persistent stump problems, the time from the injury to obtaining a permanent prosthesis, wearing comfort of the prosthesis, walking distance and restrictions in mobility); and factors related to work and policies (salary, higher job involvement, good support from the implementing body and the employer and social support network).

CONCLUSIONS

Subjects have problems returning to work after lower limb amputation. Many have to change their work and/or work only part-time. Vocational rehabilitation and counselling should become a part of rehabilitation programme for all subjects who are of working age after lower limb amputation. Better cooperation between professionals, such as rehabilitation team members, implementing bodies, company doctors and the employers, is necessary.

Prosthetic rehabilitation of persons with lower limb amputations due to tumour

The retrospective study was to analyse some characteristics of patients with lower limb amputations due to tumour, as well as the prosthetic rehabilitation. From 2000 to 2004, we observed 46 patients (25 men and 21 women) who were admitted prosthetic rehabilitation after a lower limb amputation due to tumours. We examined their medical documentation and recorded their general clinical status paying a special attention to the local status of the stump. The average age of patients was 51 +/- 17.11 years. Osteosarcoma was the most frequent cause in 26%. The trans-femoral amputation was in 50% and the knee disarticulation was in 8.7%. The average duration of prosthetic rehabilitation was 35 +/- 7.94 days. The average daily use of the prosthesis was 5.5 h. At the time of admission for rehabilitation, 10.9% of patients were using wheelchairs, 8.7% were using walkers and 80.4% were using two crutches to assist their walking abilities, whereas at the time of discharge 89.1% of patients used two crutches and 4.4% used one crutch for assistance, while 6.5% were able to walk unassisted. The adequate prosthetic rehabilitation in patients with lower limb amputations due to tumour is important preconditions for reintegration into the family and community.

Total hip replacement for proximal femoral tumours: our midterm results

Data from 44 patients (23 males, 21 females) with a median age of 39 (range 13-80) years who underwent total hip arthroplasty for proximal femoral tumours (1994-2004) were analysed. The histological diagnoses included 14 metastases, six osteosarcomas, six chondrosarcomas, four Ewing's sarcomas, four giant cell tumours, three malignant fibrous histiocytomas, two parosteal and two periosteal osteosarcomas, and one each primary neuroectodermal tumour, myeloid disease, and aneurysmal bone cyst. Twenty-one patients (48%) had pathological fractures. The cause of the pathological fracture was metastasis in 12 patients (57%). Twenty-eight patients (64%) had soft tissue invasion. Complications observed in 17 patients (37%) were local recurrence in two, postoperative haematoma in two, dislocation of prosthesis in five, deep infection in six, and one patient died of myocardial infarction in the early postoperative period. During our midterm survival analysis, functional results were excellent in 25% of patients, good in 57%, fair in 12%, and poor in 6%.

Are Canadian prostheses used? A long-term experience

The Canadian prosthesis is indicated for the more proximal levels of amputation of the lower limb (very short trans-femoral, hip disarticulation and hemipelvectomy cases); it is frequently rejected by many patients for different reasons (awkwardness, intolerance of the socket, excessive energy expenditure to ambulate among others). The objective was to analyse the use or rejection of Canadian prostheses (n = 23) after an 8-year follow-up study (range: 2 -16 years). The sample consisted of 52% men and 48% women, and the average age at the time of amputation was 52.26 +/- 19.71 SD years (range: 1-74 years). The most frequent aetiology was malignant tumour (56.5%). Eight of the subjects continued to use the prosthesis through the entire study (34.7%). Gender, age, and aetiology were not significant determinants of use. The daily use was 12.5 h per day. The rejection of the Canadian prosthesis was after 20 months of use (range: 2-48 months), and the main reasons were death (all tumour causes), intolerance to the socket, or difficulty in ambulation. In conclusion, many years after their discharge from rehabilitation services, more than one-third of the sample (34.7%) were wearers of the Canadian prosthesis.