Limb deficiency has a significant impact on the involved person, with upper limb absence presenting a materially different set of issues than lower limb absence. The primary objectives in fitting a patient with a prosthesis are to enhance their independence in performing daily activities, and to improve their quality of life. For lower limb absence, the primary issues are safety, stability, and the ability to ambulate in a manner consistent with their overall health. The primary objectives in prescribing upper limb prosthetics are function, durability, appearance, comfort, and usability of the device. This article discusses the nuances associated with managing these patients.
Key points
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Limb deficiency has a significant impact on the involved person, with upper limb absence presenting a materially different set of issues than lower limb absence.
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The prescription criteria for both populations are dependent on factors beyond the anatomic involvement, or level of the deficiency.
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Although not quite reaching the definition of “controversial,” there is disagreement and variability within the rehabilitation community as to the approaches taken regarding the type, timing, and combination of devices prescribed.
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In addition, there are guidelines provided by the Center for Medicare Services (CMS) and other payers that impact prescription development.
Statistical snapshot
Excluding military populations, and including acquired and congenital limb absence, it is estimated that in the United States there are approximately 1.7 million people living with limb loss. It is also estimated that 1 out of every 200 people in the United States has had an amputation.
The main cause of acquired limb loss is poor circulation from arterial disease, with more than half occurring in patients with diabetes mellitus ( Fig. 1 ). Amputation may also occur after a traumatic event or for the treatment of bone cancer. This is in contrast to congenital limb deficiency, where a person is born with complete or partial absence of a limb. It has also been documented that congenital upper limb deficiency occurs 1.6 times more often than lower limb ( Fig. 2 ).
Statistical snapshot
Excluding military populations, and including acquired and congenital limb absence, it is estimated that in the United States there are approximately 1.7 million people living with limb loss. It is also estimated that 1 out of every 200 people in the United States has had an amputation.
The main cause of acquired limb loss is poor circulation from arterial disease, with more than half occurring in patients with diabetes mellitus ( Fig. 1 ). Amputation may also occur after a traumatic event or for the treatment of bone cancer. This is in contrast to congenital limb deficiency, where a person is born with complete or partial absence of a limb. It has also been documented that congenital upper limb deficiency occurs 1.6 times more often than lower limb ( Fig. 2 ).
Contraindications
For lower limb amputees, various factors can present as barriers to initiating prosthetic prescription and fitting, with some manifesting immediately postoperatively and others in the days, weeks, and months that follow. Among the postsurgical complications that present contraindications for early prosthetic consideration are the following:
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Blood loss requiring transfusion
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Deep vein thrombosis
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Pulmonary embolism
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Cardiac complications including arrhythmia, congestive heart failure, and myocardial infarction
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Systemic complications including pneumonia, renal failure, stroke, and sepsis.
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Complications at the surgical site include hemorrhage or hematoma, wound infection, and failure to heal requiring additional operative interventions, such as split-thickness skin grafting, hematoma evacuation, soft tissue debridement, stump revision, and conversion to above knee amputation after below knee amputation.
Among the conditions that manifest postoperatively that can become contraindications or that complicate successful prosthetic fitting are joint contractures, neuromas, severe phantom pain, reflex sympathetic dystrophy, bursitis, and tendonitis. There are other skin and soft tissue complications that are potential contraindications to prosthetic prescription, but that can in many instances be overcome using creative prosthetic socket designs and/or compensating interface material. These conditions include thin and inelastic “brittle” diabetic skin, or skin and soft tissue compromised by burns, inelastic grafts, tissue adhesion, or severe scarring. Lastly, inadequate cognitive abilities or poor compliance can also obstruct successful prosthetic use.
Levels of involvement
The level and length of the involved limb provide a basic anatomic guide to prescription development ( Fig. 3 ). From superior to inferior levels for upper and lower limb involvement, the generally accepted descriptive terms are as follows:
Upper limb
- a.
Forequarter
- b.
Shoulder disarticulation
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Transhumeral, or above elbow
- d.
Elbow disarticulation
- e.
Transradial or below elbow
- f.
Wrist disarticulation
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Partial hand
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Digital/finger/thumb
- a.
Lower limb
- a.
Hip disarticulation
- b.
Transfemoral or above knee
- c.
Knee disarticulation
- d.
Transtibial or below knee
- e.
Syme
- f.
Partial foot
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Hindfoot
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Boyd
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Pirigoff
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Forefoot
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Toes (typically at the metatarsophalangeal joint)
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Transmetatarsal
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Lisfranc
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Chopart
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- a.
Consultation, managing expectations
The benefits of a patient-centered multidisciplinary “team” management of amputee rehabilitation, including development of prescription criteria, cannot be overstated. Recent comprehensive analysis of this approach reinforces its importance in any setting, institutional or otherwise.
In an institutional setting, such as a rehabilitation hospital or a rehabilitation department within a hospital, opportunities to apply these principles take place in a regularly scheduled amputee clinic, or in some form of periodic rounds. The formally assembled rehabilitation team consisting of the medical doctor and specialists in each of the allied health disciplines brings unique and mutually respected knowledge of their particular specialty to the discussion, ultimately reaching consensus on the optimal preprosthetic and prosthetic treatment plan, which is then formally “prescribed” by the physician.
In the more common private practice environment, efforts to apply these same principles should be considered as the prescription is developed. Because in most cases the team is not necessarily working in the same location, a more practical sequence of events prescribed by the managing physiatrist or surgeon is to first refer the patient to experienced clinical specialists for a prosthetic consultation or occupational and physical therapy consultation and evaluation. Using common methods of sharing of electronic medical records, and/or other communication pathways (email, Skype, GoToMeeting, and so forth), the clinical notes and other relevant information can be shared as it would in the formal rehabilitation team, providing cooperatively developed and appropriate results.
Developing an understanding of and subsequently managing the expectations of the patient and family also contribute to achieving a successful outcome. This is best accomplished with the help of an experienced prosthetist capable of discussing and demonstrating the various foot, ankle, and knee systems for the lower extremity amputee, and the components of an upper limb prosthetic system and the variety of joint and terminal devices (TDs) available for their level of involvement. In upper and lower limb cases, methods of attachment or linkage of the device to the affected limb, and realistic timelines for staged and progressive use, training, and ultimately integration of the prosthesis into their daily activities should also be covered topics.
Balancing function and form
Comprehensive prescription development process takes into consideration the relative importance to the patient of the polarized elements of function and form. Consistent with this fact is the fundamental premise that any and all prosthetic solutions involve some level of compromise, trading elements of function for more realistic appearance, and vice versa. Identifying the patients’ priorities, based on their anticipated use at home, work, and/or during recreational activities, they can more readily understand and ultimately accept these tradeoffs. Discussion of these essential compromises repeatedly by various members of the rehabilitation team early in the preprosthetic period prepares the patient and family for a successful and acceptable outcome.
No currently available technology can accomplish these polarized goals in one device. It is safe to assume that higher-functioning systems, whether for upper or lower limb, sacrifice elements of aesthetic realism for functional capability. Although the appearance of lower extremity prosthesis can be more easily hidden under clothing than an upper limb device, the shape and appearance of lower extremity prosthesis can also be important to lower limb amputees. When the appearance is not important to the wearer, the choice is often made to leave the components uncovered and therefore more visible. Ultimately these opposing factors in the equation are understood and accepted by the patient and family, and incorporated into an optimally devised prosthetic prescription.
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