Functional Outcome Following Lower Limb Amputation Heikki Uustal

Functional Outcome Following Lower Limb Amputation Heikki Uustal, MD Prosthetic/Orthotic Team JFK-Johnson Rehab Institute Edison, NJ 1

Epidemiology of Amputation n n n Approx. 50, 000 trans-tib amp per year Approx. 30, 000 trans-fem amp per year 50 -70 % are fitted with a prosthesis Greater than 1, 000 amputee survivors in the US 70, 000 new prostheses fitted per year Annual cost of nearly 1 Billion dollars per year 2

Morbidity Incidence of second limb amputation in the older dysvascular population: n n n 1 year 15 % 3 years 30 % 5 years 50 % 3

Mortality n n n Surgical mortality rate is 2 -15 % (depends on underlying disease and comorbidity) Dillingham reported 4% mortality rate in trans-tibial amp and 10% rate in transfem 5 year survival rate for older, dysvascular patients is 50 % following amputation 4

Increased Energy Cost By Level of Amputation n n Trans-tibial Trans-femoral Hip dis-artic Bilateral amp 20 -45% 40 -60% 60 -100% 100 -200% 5

How Do We Measure Functional Outcome? n n n Any wearing of the prosthesis Any use of the prosthesis Household ambulators Community ambulators Return to previous activity Medicare Functional Levels (0 -4) 6

Which Factors Affecting Outcome are Studied the Most? n n Age Cause of amputation Level of amputation Co-morbidity 7

PREDICTING WALKING ABILITY FOLLOWING LOWER LIMB AMPUTATION: AN UPDATED SYSTEMATIC LITERATURE REVIEW Jason T. Kahle, 1, 2 M. Jason Highsmith, 3, 4, 5 Hans Schaepper, 6 Anton Johannesson, 7 Michael S. Orendurff, 8 and Kenton Kaufman 9 Technol Innov. 2016 Sep; 18(2 -3): 125– 137. n n A total of 319 unique studies covering 50 years were identified through the electronic search. Of these, 298 were eliminated, leaving a total of 21 for full evaluation. Fifty percent of the included studies were prospective, 38% were retrospective, and 3% were SRs. Cohort and crosssectional designs were the most common designs The following predictive factors were more strongly supported: ability to stand on one leg, cognition and mood disturbance, gender, pre-amputation living status, and cause of amputation. The most strongly supported factors emerging from the search when considering prosthetic candidacy were: amputation level, physical fitness, age, and comorbidities. 8

The Dilemma Unlike upper limb amputation, there are several different clusters of patients with distinct ages and etiologies for amputation. Therefore, predicting functional outcome needs to address each group separately. Young traumatic Middle-age dysvascular Older dysvascular 9

Measurement Tools 10

Kerstein Functional Levels (ADL and mobility) 11

Narang Functional Levels (mobility only) 12

Francis Mobility Levels (mobility only) 13

Hanspal Mobility Levels (mobility only) 14

Siriwardena Walking Index (mobility only) 15

Medicare Functional Levels 1995 (attempts to correlate function to prosthetic components) n n n Level Level 0 1 2 3 4 - Patient is non-ambulatory Transfers or limited household Limited community ambulator Unlimited community ambulator High energy activities 16

Other Functional Assessment Tools n n Barthel Index and FIM score are very broad based tools with very little focus on mobility Bob Gailey’s Amputee Mobility Predictor (AMP) tries to assess mobility function with and without a prosthesis, and to predict maximum potential 17

Selected Study Results 18

Gailey 1999 n n n Studied 166 older amputee patients to determine validity of Medicare Functional Levels Found some consistency in amputee performance Found inconsistencies in assignment of the prosthetic components 19

6 Minute Walk Distance 20

6 Minute Walk Velocity 21

Medicare Functional Levels vs. Foot Worn 22

Medicare Functional Levels vs. Knee Worn 23

Burger 1997 young, traumatic amp. 20 year follow-up n n n 70 % used prosthesis > 7 hours per day 50 % walked without any aids 50 % climbed > 20 steps per day 24

Walker 1994 young, traumatic n n 80 % trans-tibial amputees ambulated independently with assistive device 70 % trans-femoral amputees ambulated independently with assistive device no no 25

Keigel young, traumatic Return to sports following amputation: n Swimming- nearly 100 % of patients who swam before amputation returned to swimming n Running- rate of regular runners dropped from 28 % to 5 % after amputation n Golf- number of patients playing golf regularly increased from 28 % to 35 % after amputation 26

Uiterwijk 1997 older, PVD, 1 yr n n 59 % using prosthesis 1 yr post-op 48 % ambulating independently (with or without assistive device) 27

Valentine 1996 older, PVD, 2 -3 yrs f/u n n 10 % died 45 % using wheelchair 10 % household ambulators with prosthesis 22 % community ambulators with prosthesis 28

Ng 1996 older, PVD, 8 yr f/u n n n 93 % wore prosthesis 83 % used prosthesis regularly 50 % household ambulators 40 % community ambulators 10 % wheelchair users (with or without prosthesis) Included only survivors !! 29

Sapp 1995 older, PVD n n 77 % used prosthesis regularly 16 % abandoned prosthesis 30

Stewart 1993 older, PVD n n 87 % of TTA wore prosthesis 70 % of TFA wore prosthesis 31

Finch 1980 older, PVD n n n 95 % returned home to live 75 % fitted with prosthesis and used for any activity in household 50 % ambulated in the community with prosthesis 32

Pinzur 1992 older, PVD n n n 84 % of all amputees returned to within 1 level of previous mobility Increased functional use correlated to hours of wearing time Use of assistive devices decreases with more distal amputation 33

Holden 1987 n n Determined that older patients needed to take a minimum of 600 steps per day to live alone in an apartment Minimum of 1100 -1400 steps per day to live in a 1 -2 level home 34

Select studies to asses predictive factors 35

Kalbaugh 2006 n n Studied 434 patients comparing obese to non-obese amputees Obesity did not affect daily use or functional level 36

Schoppen 2003 n n Studied 46 older, dysvascular patients Found better outcomes: • Younger age • No cognitive impairment • Able to balance on 1 leg 37

Davies 2003 n n n Studied 281 dysvascular patients All patients under 50 ambulated in home and community Over age 50, only 50% of TTA and 25% of TFA ambulated in the community 38

Conclusions n n There is no consistent functional outcome measure being used for successful amputee prosthetic rehabilitation About 80 % of young, traumatic amputees ambulate with a prosthesis About 56 % of older, dysvascular amputees ambulate with a prosthesis Morbidity and mortality is very high in dysvascular patients (50/50 rule) 39

Conclusions n n Only predictive factors seem to be younger age, amputation level, physical fitness, comorbidities No good correlation yet between prosthetic componentry and functional outcome 40

Thank You 41