Bilateral Transfemoral Amputation Due to Vascular Insufficiency

I recently had the opportunity to evaluate a very nice gentleman in his sixties who had ambulated briefly with a prosthesis as a unilateral transfemoral amputee but had later undergone transfemoral amputation of his surviving leg as his circulation worsened. When we met, he was independently mobile in the community using a powered chair whose cost had been covered by Medicare. At the time of our meeting, it had been more than a year since he stopped walking.

He was interested in whether prostheses would increase his independence further, and particularly what advanced technology components could offer. Examination revealed that his residual limbs were well healed and non-tender and he had excellent motivation. The newer amputation was in the proximal third of the femur while the older one was a bit higher than mid-thigh. Before responding to his question, I asked what activities he performed on a regular basis and what he could not do or found difficult that he would like to accomplish.

It quickly became clear that he was a very resourceful and talented fellow who had adapted his home environment to maximize his independence. He was able to do everything he wished in his home, and readily transferred into the car from his power chair so he could participate in any community activities he wished. He had also modified his farm equipment by creating a series of progressively higher "tables" so he could climb up several feet from his chair into the operator's seat. He continued to run those tractors and loaders with hand controls, while his son took over those with foot controls.

His primary complaint was the difficulty in climbing up into and down from his heavy equipment, and this was what he wanted to do with artificial limbs. He also wanted to walk within the house or within the community for short distances but realized that he would continue to use the wheelchair for distance mobility. When he said that he wanted a frank opinion, without any sugar coating, I told him gently that it was extremely unlikely that prostheses would make ascending and descending from his equipment easier, safer, or faster and that I would recommend that he consider adapting his existing chair seat with a power riser or installing a commercial scissor lift adjacent to where his equipment is parked. I promised to research some examples of such environmental adaptations and to forward them to him for his review.

We then discussed the possibility of a trial with short prostheses, often called "stubbies", since these are generally the best way to approach such bilateral high-level fittings. I noted that some people find short prostheses so useful around the home that they use them long term, primarily because the effort and balance required are far less than with full-length artificial limbs. Prior to considering such a trial fitting, I urged him to speak with a Board Certified specialist in Physical Medicine and Rehabilitation with significant experience in amputee rehabilitation to verify that it would be safe and reasonable to attempt to walk with such devices despite his cardiac insufficiency and vascular condition. Since prostheses would not address his primary goal of ascending and descending heavy equipment, and because he was already independent in activities of daily living at home, he was not particularly interested in this consideration.

Clinical Literature

The prosthetic Resident who accompanied me during this evaluation was a bit surprised that I responded so immediately about the limitations of bilateral transfemoral prostheses in this case. We than had a discussion about what the available literature shows, which overwhelming supports my recommendation.

Orthopaedic surgeon Tom Moore, MD and colleagues published a good retrospective review based on their experience with 157 patients in North Carolina in the late 1980s. [Prosthetic usage following major lower extremity amputation. MOORE TJ, BARRON J, HUTCHINSON F ... [et al.]. Clin Orthop 1989: 238, 219-224] One of their key findings what that when the etiology of the amputations was dysvascular, it was extremely unlikely that individuals with bilateral transfemoral amputations would remain prosthetic ambulators, although the outcome was less bleak when one biological knee remained intact. A few years later, physiatrist Alberto Esquenazi, MD co-authored a paper that retrospectively reviewed 61 bilateral cases showing that most achieved household ambulation with prostheses after inpatient rehabilitation and showed ongoing improvement 90 days following discharge. The exception was those individuals with bilateral transfemoral loss, who found long term use of prostheses very difficult. [Bilateral lower limb amputee rehabilitation: a retrospective review. TORRES MM, ESQUENAZI A. West J Med 1991: 154, 583-586] A group of Dutch physicians showed similar results in their review of 31 bilateral amputees a few years later. [Functional outcome of rehabilitated bilateral lower limb amputees. DE FRETES A, BOONSTRA AM, VOS LDW. Prosthet Orthot Int 1994: 18, 18-24] In summary, I am not aware of any published studies showing much long term success ambulating with bilateral transfermoral prostheses by elderly patients whose amputations were due to poor circulation. These findings were the basis for my frank advice to this gentleman. It is important to note that these bleak statistics may not apply to more physically fit individuals, to younger amputees, or to those with traumatic loss or congenital absences. Most such individuals are able and willing to attempt prosthetic ambulation and should have a chance to experience for themselves the effort and benefits that are involved. I favor the approach of initially fitting bilateral short prostheses and then lengthening them gradually as the patient masters their use for this group too. Orthopaedist Paul Dougherty MD recently published a long-term review of 23 Vietnam veterans with bilateral traumatic amputations at the transfemoral level. [Long-term follow-up study of bilateral above-knee amputees from the Vietnam war. DOUGHERTY PJ. J Bone Joint Surg 1999: (81A) 1384-1390] He concluded that most were or had been employed and that they generally lived productive lives despite the significant physical disability they had to overcome, noting that about 20% continued to use bilateral prostheses even thought they were now in retirement age.

There are probably two major reasons why long term use of bilateral transfemoral prostheses is so challenging. The first is a technological limitation: there are currently no powered prosthetic knees that can lift or propel the amputee up stairs, ramps, or ladders. Perhaps the research conducted in Quebec by Victhom will lead to a new class of components that offer such performance, but until then they are primarily useful for ambulation on level surfaces or mild slopes.

The second major limitation is the tremendous energy requirements to balance and ambulate with full-length transfemoral prostheses. This was studied in the 1990s even though it is extremely difficult to recruit bilateral TF amputees to participate in such strenuous protocols. Crouse et al looked at a single bilateral amputee and 3 controls in a progressive treadmill test, concluding that both full-length and short prostheses required significantly more energy than normal ambulation. [Oxygen consumption and cardiac response of short-leg and long-leg prosthetic ambulation in a patient with bilateral above-knee amputation: comparisons with able-bodied men. CROUSE SF, LESSARD CS, RHODES J ...[et al]. Arch Phys Med Rehabil 1990: 71, 313-317] A 1995 study comparing 5 bilaterals with 5 non-amputees reached similar conclusions, noting that walking at a much slower self-selected walking speed did not significantly normalize the subjective or objective effort required to walk. [Physiological demands of prosthetic ambulation among bilateral above-knee amputees (abstract). HOFFMAN MD, SHELDAHL LM, BULEY KJ. Arch Phys Med Rehabil 1996: 77, 930]

Of course, any clinician who has seen an individual who is an excellent ambulator with bilateral transfemoral prostheses visibly sweating after a one block walk at a very slow pace is not surprised by these data. But, when both clinical experience and available evidence confirm that it is physically demanding to walk on dual transfemoral prostheses, there should be little doubt of the accuracy of the observations. My conclusion is that it is very difficult to walk longer distances with bilateral TF prostheses for people with acquired traumatic amputations and nearly impossible for individuals with dysvascular losses. Children and folks born with a congenital absence are, in my experience, the group most likely to choose prostheses long term and to continue ambulating as adults and seniors. This population often learns to balance well enough to walk hands free in a crowd, which is uncommon for other etiologies that result in bilateral TF loss.

So, as an experience prosthetist, I must balance the reality of how tough it is to master two artificial limbs at this level with my desire to give every amputee a chance to reach their maximum potential. Because of the physical effort and energy required to walk with two TF prostheses, as well as the consistent results in the literature, I am very cautious about recommending anything other than a trial with short prostheses for seniors with severe vascular disease, and even then it is contingent on obtaining medical clearance that they can tolerate the stress of gait training.

For those adults who are more physically fit, I encourage a preliminary trial with "stubbies" and in many cases this leads to success with taller prostheses, sometimes with free knees. Those who find short prostheses too physically demanding typically then understand that longer artificial legs are even harder to master, and often become much more willing to focus on wheelchair mobility and independence. Those who are denied a trial with "stubbies" often wonder if they could have succeeded with prostheses, so a personal experience with reality is generally useful regardless of the results.

Children have such energy reserves, and their prostheses are so short due to their stature, that I generally suggest transitioning them quickly into full-length limbs or omitting the "stubby" phase entirely. Of course, all these decisions are individualized based on the details of each specific case, so these comments are intended as food for thought and not specific recommendations for managing particular patients or for creating prosthetic coverage policies.

Independence Without Prostheses

Because the gentlemen I was evaluating had such specific goals, I felt he would be best served by modifying his work environment. One option might be to add a seat lift to his existing wheelchair. There are a number of sources for such products on the Net and many Durable Medical Equipment stores can provide installation and ordering assistance.

Another possibility would be to place a portable scissor lift or lift table where the equipment is parked. These devices are far less complex than two artificial limbs and therefore less costly, and should do a much better job of lifting this bilateral TF amputee four feet higher than the seat of his power chair to facilitate transfers into heavy equipment.

Since 1979, the Breaking New Ground Resource Center in Purdue University's Department of Agricultural & Biological Engineering has been researching and documenting adaptations to enable farmers and ranchers with physical disabilities to continue their life's work. Their web site is widely acknowledged as one of the best sources for such information.

One of their best publications has been in my professional library for years. It is called The Toolbox and is now in its Third Edition. This compendium illustrates a broad array of successful adaptations to specific agricultural equipment with illustrations and sources for additional details. Many are one-of-a-kind modifications created by individuals themselves although commercially available options are also featured.

The table of contents summarizes the scope of information in this resource:

I. Introduction

A. Preface
B. Acknowledgements
C. Table of Contents

II. Tractors & Self-Propelled Equipment

Operator Station Access

A. Mast-Lifts
B. Linear Actuator Lifts
C. Independent Lifts
D. Added Steps & Hand Holds

Operator Station Accessories

E. Cab
F. Seating
G. Rear View Mirrors
H. Blind Spot Camera Systems

Control Modifications

I. Brake Control Modifications
J. Hand Controlled Clutch
K. Combine Header Control
L. Steering
M. Guidance Systems
N. Hydraulic Control Transfer
O. Other Control Modifications

Hitching

P. Three-Point Quick Hitching
Q. Drawbar Quick Hitches
R. Hydraulic and PTO Connectors
S. PTO Coupling
T. Front End Loader Attachments
U. Winch Hitches

Self-Propelled & Other Equipment

V. Excavating & Earthmoving
W. Skid Loaders
X. Skid Loader Modifications

III. Livestock Handling & Housing

Fencing & Gates

A. Drive-over Gates
B. Fence Post Bracing
C. Manual/Spring-loaded Gate Openers
D. Powered Gate Openers
E. Post Drivers
F. Miscellaneous Gate & Fence Devices
G. Wire-gate Latches

Equine

H. Adaptive Riding Saddles & Accessories
I. Horse Mounting Equipment

Beef Cattle

J. Calving and Calf Care Equipment
K. Cattle Restraint Equipment

Dairy Cattle

L. Dairy Parlor Aids
M. Stanchion Barn Milking Aids

Swine

N. Swine Operations Modifications

Poultry

O. Poultry Production and Processing Equipment

Sheep

P. Sheep Handling

General Livestock

Q. Watering
R. Feeding
S. Health Equipment

IV. Crop & Materials Handling/Storage

Seed & Grain

A. Bin Level Indicators
B. Grain/Feed Bin Access
C. Grain Handling
D. Bulk Seed Handling

Hay & Forages

E. Round Bale Handling
F. Square Bale Handling

Bulk Materials

G. Adaptive Shovels
H. Pickup Truck Dump Beds
I. Tarps
J. Trailers
K. Wheelbarrows

Chemicals & Liquids

L. Sprayer and Chemical Tanks

V. Agriculture-Related Enterprises

A. Wood Handling Equipment
B. Orchard Aids
C. Vegetable Harvesting Carts

Shop Equipment

D. Creepers
E. Other Maintenance Equipment
F. Metalworking Equipment
G. Shop Hoists & Lifts

Hand Tools

H. Easy-Grip Tools
I. Reduced Force Tools
J. Grease Guns
K. Clamping Tools
L. Modified Hammers & Nailing
M. Prosthetic Tools
N. Low Vision Tools

VI. Shops & Shop Tools

Accessibility & Layout

A. Accessible Farm Shops
B. Tool Storage

VII. Trucks and Off-Road Vehicles

Truck Access and Controls

A. High-tech Automotive Controls
B. Low-tech Automotive Controls
C. Pickup Cab Access
D. Pickup Truck Wheelchair Loaders

Truck Hitching and Hauling

E. Pickup Hitching Aids
F. Pickup Bed Access
G. Pickup Truck Hoists

Off Road Vehicles

H. Extreme Terrain Vehicles
I. All Terrain Vehicles
J. Utility Vehicles

Off Road Vehicle Modifications

K. Accessories
L. Control Modifications
M. Safety Modifications

VIII. Outdoor Mobility

Manual

A. Outdoor Manual Wheelchairs
B. Wheelchair Accessories

Powered

C. Outdoor Power Wheelchairs
D. Wheelchair Riding Vehicles
E. Mobility Carts

Paths

F. Paths & Non-slip Surfaces

IX. Lawn & Garden

Gardening

A. Raised Garden Beds
B. Gardening Tools and Accessories
C. Planting Tools
D. Low-vision Gardening

Lawn Care

E. Lawnmowers
F. Yard Tongs

X. Outdoor Recreation

Fishing

A. Accessible Pontoon Boats
B. Casting & Reeling
C. Fishing Pole Holders

Hunting

D. Gun Mounts
E. Hunting Modifications
F. Accessible Hunting Stands

Other

G. Accessible Picnic Table

XI. Safety & Health

A. Respiratory, Vision, Hearing
B. Adaptive Clothing
C. Arm Prosthetics and Modifications
D. Communication Equipment

XII. Case Studies

A free PDF file with excepts from this publication can be downloaded by clicking here. Three examples of modifications of farm machinery are reproduced below to illustrate the sort of information contained in The Toolbox. The first is one method to make a tractor more accessible, the second is a detachable lever for a clutch pedal, and the third depicts a boom lift and hand controls for a bulldozer.

One of the hallmarks of a professional is an honest acknowledgment of the limitations in what their expertise can offer. In my experience, independence without artificial limbs is the most effective choice currently available for a number of people with bilateral high level upper or lower limb loss, and should always be considered one reasonable option to evaluate.

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