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Chapter 24A - Atlas of Limb Prosthetics: Surgical, Prosthetic, and Rehabilitation Principles

Special Considerations: Fitting and Training the Bilateral Lower-Limb Amputee

Douglas G. Smith, M.D. 
Ernest M. Burgess, M.D. 
Joseph H. Zettl, C.P. 

The bilateral lower-limb amputee has throughout recorded medical history presented a special challenge for the rehabilitation team to provide a degree of mobility that would allow a more normal place in society. Persons with high-level amputations or congenital limb deficits that present a similar functional loss can occasionally walk without a prosthesis by using crutches and a swing-through gait. This requires very good trunk and upper-body strength, sense of balance, and muscle control. Such ambulation is seen very occasionally in children and young adults. In most cases, assistive devices are necessary to stand and walk. Many simple as well as ingenious means have been used by the amputee to move from place to place. Often the amputees self-designed and made devices that best suited their needs.

The surgeon, the prosthetist, and the rehabilitation team have at their disposal today a wide variety of prosthetic and assistive aids for providing comfortable standing and walking. The remarkable degree of functional restoration now possible can often permit the bilateral leg amputee to participate in a life-style that socially and vocationally overcomes his physical handicap.

Bilateral lower-limb amputations are much more frequent currently than in the past largely secondary to an aging population with an increased incidence of peripheral vascular disease and diabetes mellitus. Improved medical management is continually increasing life expectancy throughout the industrialized world. As people live longer, the complications of diabetes, peripheral vascular disease, and other chronic medical diseases progressively increase the frequency of lower-limb loss. In 1985, there were 112,500 nontraumatic lower-limb amputations in the United States, and 50% of these were in patients with diabetes. The 3-year survival rate after a major amputation for diabetes or vascular disease is about 50% and is essentially unchanged from the mid-1960s to the early 1980s. Since these disease states are systemic, studies have shown that approximately 25% of the original group, or about 50% of surviving patients, can be expected to lose the second limb by 2 to 3 years following the first amputation. The quality of surgical, medical, and rehabilitative care further results in a life expectancy of months and often years as a bilateral lower-limb amputee. Mobility by ambulation with prostheses profoundly improves the quality of life as compared with a wheelchair existence.

There are also an increasing number of bilateral lower-limb amputees as a result of trauma, especially in war or natural disasters. The current high quality and availability of military and emergency medical care allows survival for many patients whose severe trauma would have been fatal in previous decades. Loss of both lower limbs is also encountered in trauma centers throughout the industrialized world. Motorcycle accidents, pedestrian involvement in car or train accidents, and severe burns are generally responsible. Most of those sustaining bilateral traumatic lower-limb amputations are adolescents and young adults. Prosthetic rehabilitation potential is usually excellent.

Bilateral congenital leg amputations and limb deficiencies encompass a small but often difficult group. With appropriate prosthetic management, rehabilitation can be surprisingly successful and rewarding in these infants and children. Even if prosthetic ambulation is not expected to continue into adult life, the independence and mobility achieved by aggressive prosthetic rehabilitation in the early years improves the general health and social development of these children.

SURGICAL DECISION MAKING

Retention of maximum limb length by amputation at the distalmost suitable level is particularly important for the bilateral amputee. There is absolutely no added benefit to having both lower limbs amputated at the same level. Even if a patient is a bilateral transtibial amputee, it is not necessary to have both legs symmetrical, and all length possible that is suitable for prosthetic fitting should be preserved (Fig 24A-1.). State-of-the-art plastic and microvascular reconstructive surgery is on occasion justified to maintain residual-limb length. This is particularly true when the amputations result from burns. Bone lengthening procedures, however, are rarely justified. The surgical management of these difficult cases requires a full knowledge of the principles of modern prosthetic management. The amputation site becomes the new interface for human contact with the environment and must be as functional and comfortable as possible (Fig 24A-2.).

Even in the bilateral amputee, there remain a few regions where it is not advisable to amputate, not only because healing may be compromised but also because prosthetic substitutions are unsatisfactory at these few levels in the lower portion of the leg. These areas include the lower fifth of the leg down to but just above the Syme-level ankle disarticulation, the very short

transtibial amputation above the attachment of the patellar tendon, and the very short transfemoral amputation in the subtrochanteric region. In each of these instances it is usually better to elect amputation at a higher level to permit improved prosthetic substitution and patient comfort.

Although optimum function is usually the primary concern in amputation, the cosmesis of the prosthetic limb replacement must also be considered. Syme ankle disarticulation and knee disarticulation levels have a bulbous end and result in a less aesthetic appearance in the final prosthesis. Patients with high cosmetic expectations might be dissatisfied with these levels (Fig 24A-3.).

In the geriatric age group, the patient's activity level, ambulatory potential, cognitive skills, vision, and overall medical condition must be evaluated to determine whether the distalmost level is really appropriate for the patient. In ambulatory patients, the goal is to achieve healing at the most distal level that can be prosthetically fit and allow successful rehabilitation. Most unilateral transtibial amputees who were successful prosthetic ambulators will master bilateral amputee gait if a transtibial or more distal amputation can be performed on the contralateral limb. The success of rehabilitation decreases dramatically if transfemoral or higher-level amputations need to be performed.

In nonambulatory patients, the goal is to obtain wound healing, minimize complications, and improve sitting balance, transfers, and nursing care. For example, a bedridden patient with hip and knee flexion contractures might be better served with a knee disarticulation or very long transfemoral amputation than with a transtibial amputation. On the other hand, a geriatric patient with a previous transfemoral amputation might be a nonambulator but still have excellent independent transfers and bathroom skills. If the patient capable of independent transfers develops contralateral foot gangrene, he might be best served by preserving all possible length and prosthetic fitting, if the goal is to continue independent transfers and bathroom activities. Such skills are extremely important in the bilateral amputee and should be given careful preoperative evaluation, even in nonambulatory patients. Careful preoperative assessment of the patient's potential and setting realistic goals can help direct surgical level selection and postoperative rehabilitation wisely.

PROSTHETIC FITTING AND REHABILITATION

Rapid prosthetic rehabilitation of the multiple-limb amputee ensures the best results in returning to an active, independent life-style. Speed of recovery is frequently indicative of how well the patient will be able to perform predetermined rehabilitation goals. This is particularly important in the management of the majority of amputees we are treating today, the elderly. The psychological and economic benefits to this patient approach are also quite appreciable. Contemporary prosthetic fitting of the bilateral lower-limb amputee can be categorized into immediate postsurgical prosthetic fitting (IPPF), early postsurgical prosthetic fitting, preparatory prosthetic fitting, and definitive prosthetic fitting. Although managed differently, previous unilateral amputees who later become bilateral and simultaneous bilateral amputees both benefit from early rehabilitation with controlled weight bearing.

Improved wound healing, the prevention of contractures, and early mobilization through the use of rigid dressings dominate the immediate and early phases. Maturation of the residual limb by comfortably, increasing weight bearing and initial gait training predominate in the preparatory prosthetic phase. Cosmesis, durability, and final gait training become important considerations in the definitive prosthetic phase. Increased sophistication of current fitting techniques, materials, and available componentry make the correct selection and application more critical than ever before as the patients proceed through these various phases of prosthetic management and training.

Immediate Postsurgical Prosthetic Fitting

Ideally, IPPF with controlled weight bearing is the initial patient treatment of choice, especially in the young traumatic amputee. The details and benefits of applying a rigid dressing (i.e., plaster of paris socket) with a pylon extension and prosthetic foot in the operating room have been adequately documented in the literature. The primary consideration is achieving rapid, optimal wound healing. This is accomplished by controlling postsurgical edema without restricting circulation. Tissue support minimizes inflammatory reaction and reduces phantom pain. The psychological benefits are significant as the patient wakes up with a prosthesis in place of the amputated limb and rehabilitation starts immediately. Carefully controlled static weight bearing can be initiated the first postoperative day or whenever the patient is physically capable of tolerating the procedure. Use of a tilt table is necessary for the bilateral amputee, with bathroom scales or other pressure-monitoring devices utilized to help regulate weight bearing. As wound healing progresses and is monitored at the various cast change intervals, weight-bearing increments are also accelerated accordingly. Actual ambulation activities are delayed until the incisions have healed and sutures have been removed. Patients with simultaneous bilateral amputations must be advanced more slowly and carefully than the previous unilateral amputee who can tolerate unrestricted weight bearing on the mature, previously amputated limb (Fig 24A-4.).

If prosthetic pylons have not been utilized initially, manually applied, simulated weight-bearing activities are administered by the therapist or the patient himself through the cast (Fig 24A-5.). The reduction in edema that results from simulated weight bearing decreases postoperative discomfort. IPPF can be implemented in any hospital setting that has a trained team of professionals available. The team consists of a surgeon, a prosthetist, a physical therapist, a nurse, and other auxiliary personnel as might be required.

Early Postsurgical Prosthetic Fitting

Under certain conditions, the surgeon may defer application of a rigid dressing 1 to 3 weeks postsurgically to or near the time when sutures are removed from the surgical incision. Although we prefer immediate use of rigid dressings, to delay until suture removal is very common in the bilateral amputee. At this stage, considerable postsurgical edema is usually evident, and residual-limb or phantom pain can be exaggerated in spite of soft compression dressings such as an elastic bandage or shrinker sock. In all probability, the patient has been restricted to bed rest or limited to wheelchair mobility, which leads to physical decompensation and muscle weakness. In a worst-case scenario, wound healing can be compromised as a result of this delay.

The early prosthetic fitting techniques employed are the same as for the IPPF. If considerable edema is evident at the initial application of the cast socket, frequent cast changes may be indicated until this condition stabilizes. If a cast socket inadvertently comes off the limb, it should not be pushed back on. Damage to the residual limb may result with associated pain for the patient. A new cast socket must be applied without delay.

Removable cast sockets, in our experience, have been unsuccessful. As the name implies, they are removable and can come off the residual limb at the most inappropriate time. The need for daily wound inspection contradicts our position of undisturbed tissue support and immobilization. Removable rigid dressings must be continuously monitored and require the complete cooperation of a reliable patient. Regular-interval full-cast changes between 7 and 10 days are adequate for dressing changes unless wound problems require more frequent attention.

Soft compression dressings supplemented by an elastic bandage or shrinker sock are less effective in achieving rapid wound healing. Residual-limb edema associated with discomfort and phantom pain is frequently evident with this form of patient treatment. It delays the recovery period unnecessarily and invites further complications in the form of joint contractures and general physical decompensation, especially in the geriatric patient.

Preparatory Prosthetic Fitting

Preparatory prostheses, also referred to as intermediate or training prostheses, are useful if the volume of the residual limb is expected to decrease rapidly in the near future or if a gradual reduction of joint contractures will require repeated prosthetic realign-ment. This is common in simultaneous bilateral amputees who cannot advance their weight bearing as quickly as unilateral patients.

Such prostheses are also indicated for evaluating a patients potential to safely ambulate or to demonstrate to a patient the energy and skill requirements associated with the use of prostheses. If used in this context, preparatory prostheses are indeed justified and present the best diagnostic and economic tool for measuring a patient's mobility capabilities. The bilateral amputee greatly benefits from this approach (Fig 24A-6.).

Component choice is carefully prescribed in consideration of the particular patient's needs. Likewise, the prosthetic socket configuration as well as design anticipates the patients requirements and is the critical contact point of the human anatomy and the mechanical substitute. Patient comfort will make the decisive difference between acceptance and rejection of the prosthesis and is therefore a high priority.

Whenever possible, the components of choice should be the same as those anticipated for the definitive prosthesis to minimize the retraining and relearning required. The economics of this practice are realistic and obvious. It is frequently prudent to utilize definitive foot-shin-knee components for the preparatory prosthesis and carry them over into the definitive device. Commercially available, prefabricated, adjustable sockets may warrant consideration in particular situations when in the opinion of the team this approach is pref-erable.

Definitive Prosthesis

Definitive prostheses are sometimes erroneously called "permanent" or "final" prostheses. These are misnomers since all prostheses wear out mechanically or require replacement due to deteriorating fit.

Never before in the history of prosthetics have pros-thetists had so many sophisticated materials and components at their disposal to serve their patients better and more effectively. High-strength, lightweight components made from titanium and carbon fibers combined with sockets fabricated with thermoplastic materials or acrylic resins result in a lightweight prosthetic construction that reduce energy consumption during ambulation activities. Improved biomechanical fitting principles and static and dynamic test socket procedures combined with flexible socket construction further enhance patient comfort and acceptance. Radiographs or xeroradiography can isolate or pinpoint residual-limb fitting problems. Recent developments in computer-aided design and computer-aided manufacture (CAD-CAM) open the door to new and exciting possibilities to better serve the multiple-limb amputee. All this demands greater knowledge and skills on the part of not only prosthetists but also the entire clinic team, who are responsible for formulating the prosthetic prescription.

Individual patient needs vary greatly among infants, children, adolescents, adults, athletes, and active and sedentary geriatric amputees. There are different requirements between males and females and important considerations to be made for vocational and recreational activities. Parents, spouses, relatives, and friends of patients also play an important role since they influence patients' expectations and reactions to their prostheses and management. Each new patient requires individual assessment and evaluation to determine his exact personal needs. While many amputation levels are similar or the same, the individual patient requirements are vastly different and must be accommodated to be effective in the overall, total rehabilitation of the patient. A patient must learn to walk before he can expect to run, if this is even physically possible.

Bilateral amputations can be of an equal level such as foot, ankle, transtibial, knee disarticulation, transfemo-ral, and hip disarticulation, or any combination of the above. Since it is the surgeon's intent to preserve all joints and all useful length in the residual limb, the prosthetist is presented with the challenge of varied amputation level combinations where prosthetic designs must interact effectively.

INFANT AMPUTEES

While statistically a very small group, children with congenital limb deficiencies present major challenges to the entire rehabilitation team. Depending on the full extent of the anomaly, infants may face continuous treatment throughout their lifetime to manage the disability. Early diagnosis, surgical intervention, and prosthetic fitting have been advocated. As a result, infants are being fitted with lower-limb prostheses as early as 8 months of age or when they attempt to accomplish a seated or an upright position.

Even high-level amputees as a result of lumbosacral agenesis have been fitted with specially designed prostheses. The initial prosthetic socket extends to the thorax for stabilization to allow an upright position and can be fit for sitting as early as 4 to 6 months.The socket is mounted on a stable platform to which casters can be mounted for mobility. Limited ambulation is accomplished in time, when the socket is mounted on a swivel walker for self-induced mobility. Following bilateral hip disarticulations, the prosthetic socket is combined with cosmetically enhanced thigh-shank-foot components that allow sitting, standing, and some limited ambulation on the principles of a swivel walker. Often these patients have multiple medical problems that require continued treatment and monitoring and may interrupt prosthetic management.

Miniaturized, commercially available prosthetic components are very limited for infants. This requires the prosthetist to design and custom-fabricate what is needed. Some upper-limb components such as manually locking elbow joints can be integrated into lower-limb infant prostheses. Since structural strength requirements are very minimal, plastic tubing can be utilized in endoskeletal designs and results in very lightweight, cosmetic appliances. Recently we have switched to aluminum tubing that is fitted into a larger-size tubing, thus allowing telescoping length adjustments for growth.

Our current, typical, initial knee disarticulation infant prostheses consist of flexible thermoplastic sockets mounted in rigid frames. This allows for socket replacements due to growth without remaking the entire prosthesis. Total-contact socket designs using a sock interface with the classical Silesian bandage or a modified version thereof has been the most frequent method of suspension. A miniaturized version of the total elastic suspension (TES) belt has also proved to be an effective option. Any suspension considerations must resolve the problems of diapers and thus should be moisture resistant and washable. Flexible or rigid pelvic band and hip joint suspension or shoulder harness suspension is seldom indicated in infants. In our experience, it is possible to fit select infants with total-contact suction suspension as early as 18 to 24 months of age. This eliminates most auxiliary suspension needs. The prerequisite is that parents be able to apply the prosthesis correctly. More frequent socket replacements as a result of suction socket fittings are not as significant as anticipated and should not be a deterrent. Recently, the introduction of the hypobaric suspension system has provided another suspension option. The system utilizes a prosthetic sock that is impregnated circumferen-tially at the midportion with a narrow band of flexible silicone that forms an effective seal on the inner socket wall and results in socket suspension. This system is appropriate even for infants.

The use of stubbies as the initial prosthesis is recommended for all bilateral knee disarticulation or trans-femoral amputees, regardless of age, who are considered candidates for ambulation and who lost both legs simultaneously. Stubbies consist of prosthetic sockets mounted directly over rocker-bottom platforms that serve as feet. The rocker-bottom platforms have a long posterior extension to prevent the tendency for the patient to fall backward initially. The shortened anterior portion allows smooth rollover into the push-off phase. As hip flexion contractures lessen and balance improves, the posterior rocker extensions can be shortened accordingly. The use of stubbies results in lowering of the center of gravity, and the rocker bottom provides a broad base of support that teaches trunk balance and provides stability and confidence to the patient during standing and ambulation. As the patients confidence and ambulation skills improve, periodic lengthening of the stubbies is permitted until the height becomes nearly comparable with full-length prostheses, at which time the transition is attempted. Knee components are usually omitted for infants since stability and balance are still developing.

The majority of infants, children, and young adults with bilateral knee disarticulation or transfemoral amputations can generate the energy required to ambulate when wearing stubbies without needing assistive devices such as crutches or canes. Assistive devices may be needed for safety and support once the patient has accomplished the transition to full-length prostheses. Such assistive devices severely compromise upper-limb function and should be avoided where possible since this alone is a major deterrent to using full-length prostheses.

Parents like cosmetically pleasing prostheses, and every effort should be made to achieve this without sacrificing comfort or function. Lightweight exoskeletal designs are also quite acceptable for use in infants, and the choice should depend on what is considered most appropriate for a particular patient and parent.

CHILD AMPUTEES

Most children, including high-level bilateral lower-limb amputees, have very high physical activity levels. They are encouraged to participate in play, sports, and recreation activities like any other child. As a result many of the children place profound physical demands on their prostheses. Prostheses in need of major servicing and repairs are a joy to the entire clinical team, for they denote a very active, well-adjusted child who is using the prostheses to their maximum potential. For this reason, durability must be considered in the design for this active group of amputees. Fortunately, with the introduction of new petrochemical-based materials that are lightweight and strong, the challenge of prosthetic durability can be met better today than ever before. Prosthetic researchers, engineers, suppliers, and manufacturers have finally started to meet the challenge of providing componentry for this very active group of young children. Some noteworthy examples of these new developments are the hip disarticulation and trans-femoral endoskeletal system with adjustable knee friction and extension assist from Otto Bock and the Child Play Seattle LightFoot from M.I.N.D. The Aqua-Flex, an all-plastic transfemoral pediatric knee-shin setup from Ford Laboratories in Richmond, British Columbia, Canada, can be used to make a waterproof prosthesis. Many components are still custom-designed and hand-fabricated by prosthetists to meet their individual patients needs.

Comfort and control of the prosthesis are directly proportional to good socket retention on the residual limb. This becomes critical in the bilateral amputee. Thus, it is advisable to use suction suspension whenever this is possible in both transfemoral and trans-tibial fittings. The need for slightly more frequent socket replacements is a small price to pay to allow improved function and comfort for the active youngster.

The use of the silicone suction socket (3S) technique has been reported and expanded to include all levels of amputation. Hypobaric suspension can also be utilized in children, as well as the conventional suspension systems such as hip control belts, waist belts, and cuff suspensions. Unstable knee joints may require the addition of side joints and thigh lacers or, at a minimum, a patellar tendon supracondylar (PTS) socket design. PTS socket configuration is also useful for short and very short residual transtibial limbs and where pistoning must be held to a minimum, such as in skin graft or burn patients. Whatever system is chosen, it must fill the needs and abilities of the patient and parents without making it technically too complex and thus frustrating.

Occasionally a patient with bilateral tibial hemimelia is encountered after bilateral Syme ankle disarticulation or transtibial amputations. Knee instability and flexion contractures are major concerns that frequently accompany these congenital limb deficiencies. Prosthetic prescription should include side joints and thigh lacers, not so much to distribute weight as to provide increased medio-lateral knee stability (Fig 24A-7.). When the knee flexion contracture exceeds 15 to 20 degrees, special socket modifications and techniques are indicated to accommodate the deformity (Fig 24A-8.). If the congenital limb deficiency is so severe that knee instability or flexion contractures prohibit prosthetic fitting, then knee disarticulation is required on one or both limbs (Fig 24A-9.).

As discussed in the infant section, the use of stubbies as the initial prostheses is recommended for rehabilitation of all bilateral knee disarticulation and transfemoral amputees who are considered candidates for ambulation and who lost their legs simultaneously. The majority of children with bilateral knee disarticulation and transfemoral amputations can generate the required energy to develop ambulatory capabilities by using stubbies without assistive devices such as walkers, crutches, or canes (Fig 24A-10.). This high performance level is not always sustainable through adulthood, but diminishes with advancing age when some become marginal users or abandon the prostheses altogether, except for cosmetic use, in favor of wheelchair mobility.

ADOLESCENT AND YOUNG ADULT AMPUTEES

This group of amputees frequently proves the prosthetic team wrong when told of physical limitations associated with multiple amputations. The news media constantly remind us of the stunning accomplishments of amputee athletes, including bilateral high-level lower-limb amputees. These runners, swimmers, skiers, rowers, mountain climbers, basketball players, etc., demonstrate the dangers of stereotyping amputees with outdated classifications. Experience has proved that patients can excel safely if given the opportunity rather than being told that they are unable to do so(Fig 24A-11.).

Most bilateral amputees perform these extracurricular recreational activities with conventional prostheses. A few, more competitive amputee athletes may have special prostheses designed to aid their accomplishments in competitive sports events. There is an abundance of materials and componentry available from which to select what is most suitable for a particular amputee. They should be allowed to evaluate different socket designs, knee components, and feet to determine the best functional combination for their needs. This is an expensive and time-consuming process but ensures the best results. Similarly, refinements of socket fit through repeated static and dynamic test socket procedures, including proper alignment of components, makes for more functional prostheses(Fig 24A-12.).

Suction suspension, including semiflexible transtibial and transfemoral sockets, is preferable for bilateral amputees, so long as the amputee is able to don and doff the prostheses effectively without assistance. Flexible brim, ischial containment transfemoral sockets provide more comfort during ambulation and when seated by providing increased clearance in the perineum. It must be noted, however, that there are numerous successful bilateral transfemoral amputees utilizing quadrilateral or modified quadrilateral suction or semisuction prostheses. Either these patients have not yet made the transition to ischial containment socket designs, or they have tried the transition but prefer to remain with their previous socket designs (Fig 24A-13.).

Early flexible inner sockets lacked durability. Surlyn and certain polyethylenes cracked and buckled under rigorous use and required frequent replacement. Improved working techniques and better materials have reduced these problems and given the prosthetist a wider choice of options. The 3S socket design, including the Icelandic Roll-on Suction Socket (ICE-ROSS) system, provides excellent suspension and minimizes the problem of excessive perspiration of the residual limbs that is commonly encountered in bilateral prosthesis use.

Dynamic-response foot and ankle components have a profound impact on socket comfort and the functional capabilities of all lower-limb prosthetic users. Amputees have noted improvement in proprioceptive feedback; improved negotiation of inclines, declines, and uneven terrain; as well as improved impact absorption and reduction of torque and shear forces. All of these enhance stability and control of prostheses and improve gait. Special foot alignment and resistance is required for the bilateral amputee for security and balance. There is an abundance of knee joint components available that aid in stability and function. For maximum durability, exoskeletal design has the advantage over endoskeletal systems. For cosmetic appearance, the endoskeletal system has a distinct advantage and is therefore favored by many females. Postfitting realignment procedures are performed much more conveniently and expediently with endoskeletal designs than with exoskeletal systems that require major labor-intensive reworking procedures to achieve alignment corrections.

Bilateral young transtibial amputees usually become excellent ambulators with a relatively normal gait without the use of external aids. Similarly, persons with bilateral partial-foot amputations, Syme ankle disarticulations, or a combination of these levels accomplish a near-normal gait. Knee disarticulation or transfemoral amputees with contralateral transtibial or more distal amputation also become accomplished ambulators but frequently prefer a cane or other assistive device. Most bilateral amputees who have lost one knee limit their daily ambulation activities and have sedentary jobs.

The simultaneously acquired bilateral knee disarticulation or transfemoral amputee requires fitting with stubbies as the initial prostheses, as previously discussed. In our experience, most adults with acquired bilateral transfemoral amputations fail to become consistent wearers of full-length prostheses but continue the use of stubbies for their daily ambulation activities. They may elect to wear the full-length prostheses for special events or cosmetic reasons only. The longer lever arm, balanced thigh musculature, and end-bearing capacity of the knee disarticulation makes bilateral full-length prosthetic use easier than for the bilateral trans-femoral amputee, but the principles and training are very similar (Fig 24A-14.). The accomplished user of bilateral transfemoral prostheses typically uses a cane and has midthigh or longer amputation levels. This patient was usually involved in recreational or sports activities prior to the amputations, is physically slim and fit, and has high endurance and good motivation. Full-length prostheses are usually designed to shorten the patient's stature slightly because balance is improved by lowering the center of gravity (Fig 24A-15.). Use of a stance-control or manual-locking knee is reserved for the shorter of the residual limbs. Different knee mechanisms can and should be utilized as required, but they must be tested and evaluated during trial ambulation. Foot and ankle components should be of the same type and function for both limbs and have a stiffer plantar flexion resistance than is required in unilateral cases. Larger foot size may improve support and stability. The patient must be able to achieve a seated and standing position independently and in less-than-ideal locations. The amputee must also be trained to return to the standing position from the ground as occasionally would be required after a fall. Bilateral transfemoral prosthetic users require a great deal of gait training by a qualified physical therapist. Negotiation of stairs, inclines, declines, and uneven terrain are complex challenges that must be learned and practiced by the patient to become an accomplished ambulator (Fig 24A-16.).

There are some possible variations in the rocker bottoms of stubbies. The use of SACH feet with the toes pointing posteriorly has been advocated by some for a smoother gait. We have utilized rocker bottoms incorporating the Greissinger foot multiaxial ankle system (Fig 24A-17.) and more recently the Flex Walk Foot fitted to tennis shoes. One triple amputee with a very short transfemoral amputation on one side is capable of briskly walking 2 miles daily for exercise. He prefers stubbies over full-length prostheses, which require much higher energy output, are cumbersome, slow him down, and instill a constant fear of falling (Fig 24A-18.). This experience is very common with the use of full-length transfemoral prostheses and restricts the majority to ambulation with stubbies only.

Adults with acquired bilateral hip disarticulation rarely become effective ambulators, but they still may request special-purpose prosthetic fittings. Specially designed and fitted sockets to allow for more comfortable seating can be provided. Full-length functional prostheses are primarily for cosmetic appearance while seated in a wheelchair, but it is possible for the patient to stand in these prostheses and initiate voluntary mobility on the principles of a swivel walker. A particularly strong patient can also accomplish a swing-through gait with the aid of crutches (Fig 24A-19.).

GERIATRIC AMPUTEES

The great majority of bilateral lower-limb amputees today are the elderly who lose their limbs secondary to diabetes and vascular disease between the ages of 55 and 95 years. In general, dismissing these patients as poor prosthetic candidates is a grave mistake and compromises the rehabilitation potential when immediate postsurgical treatment is delayed. Lack of exercise and mobility will encourage joint contractures, weaken the patient, cause loss of independence, bring on depression, and may even become life-threatening. No patient group benefits more from immediate postsurgical prosthetic fitting, including early fitting of preparatory or definitive prostheses, than the geriatric bilateral amputee. The challenge of rehabilitating these patients is frequently complicated by the presence of other illnesses. Diabetes, chronic infection, kidney disease, cardiovascular disease, respiratory disease, arthritis, and impaired vision are complicating factors that require careful consideration when evaluating patients. Delayed wound healing, slowly healing lesions, and neuropathy warrant additional consideration. Of these complicating factors, diabetes appears to be the leading cause of second limb loss.

Fortunately, the time interval between the first and second limb loss, which can be months or perhaps years, makes learning to ambulate easier for the patient than if both limbs are lost simultaneously (Fig 24A-20.). Chronologic age alone should not determine whether an amputee is a prosthetic candidate. A 90-year-old patient can be in better physical shape than a 50-year-old and use prostheses accordingly. While the patient must be able to understand and follow instructions for proper use of the prosthesis, this may not be always the case immediately preceding or following amputation when systemic toxicity from an infected limb may cause the patient to act temporarily confused or unaware of the ongoing proceedings. Sometimes patients are wrongly diagnosed as prosthetic noncandidates and denied prostheses. We must give the patient the benefit of the doubt and provide at least preparatory prostheses to evaluate ambulation potential. Even if prostheses are used only to assist in transfer activities, they are justified.

Preoperative and postoperative patient education is an important adjunct to rehabilitation. Teaching a patient proper hygiene and care of the residual limbs and the prostheses is vital. Amputee support groups, now available in many localities, are a great benefit to patients in learning about their disability and in being able to discuss matters with other amputees that they may be reluctant to discuss with clinic team members. Older patients require much more time, understanding, patience, and encouragement. They thrive on praise, and even small improvements give encouragement and aid in progress. They are frequently forgetful and need to be reinstructed frequently. Spouses and other family members should be encouraged to participate during fitting and training sessions. Their input is important, and their concerns should be addressed in detail.

Prosthesis design and componentry must be based on careful individual evaluation of all pertinent factors. The most sophisticated prosthesis with hydraulic or pneumatic swing-phase control, rotators or torque absorbers, and energy-storing foot is totally inappropriate if we are dealing with a marginal ambulator who uses the prosthesis on a very limited indoor basis. Any type of prosthesis is inappropriate if the patient is unable to don and doff it properly. Bilateral transfemoral prostheses are too difficult to manage for most geriatric patients and, if requested, are primarily for cosmetic effect while using a wheelchair. Even stubbies are often too difficult for this group to master, and it is a very rare exception to find someone willing to try and to succeed in ambulating with them regularly (Fig 24A-21.). Use of a transfemoral and transtibial prosthetic combination is limited to only a few very energetic patients and then for only limited use around the house.

Socket design must be such that the patient can don and doff the prosthesis independently. For transtibial prostheses, this may require that special pull-on loops be attached to the socket or liner for patients with arthritis of the hands. Similarly, a patient must be able to properly install a wedge suspension system in a PTS design, or other alternatives must be utilized. A neo-prene suspension sleeve is an excellent means of auxiliary socket suspension if the patient can apply it properly. If the patient cannot handle buckles, Velcro closures should be substituted. Side joints and thigh lacers are infrequently required for an unstable knee or very short residual transtibial limb. They greatly complicate donning the prosthesis, and should be avoided if other alternatives exist. Little frustrations can lead to total rejection of the prostheses and must be avoided. The basic rule is to keep them as simple as possible.

Although suction socket suspension is the preferred means of suspension, the bilateral geriatric amputee can seldom master the conventional donning technique. An alternative method that merits consideration is use of the liquid-powder, wet-fit method, in which the patient liberally applies a special liquid lubricant that allows donning the prosthesis. This lubricant rapidly dries into a powder that allows retention of the socket by suction. Another option is to provide flexible, roll-on silicone liners that allow donning and doffing while seated. Hyperbaric socket suspension offers another excellent option.

The majority of bilateral geriatric transtibial amputees master ambulation with the aid of a walker or cane. An amputee with transtibial amputation and a more distal level on the contralateral side almost routinely achieves ambulatory status with or without a walking aid (Fig 24A-22.). Prostheses for geriatric amputees should be made as light as possible with contemporary techniques. They should be of relatively simple design and not contain superfluous components that may be of questionable benefit to limited ambulators.

Occasionally geriatric patients with bilateral congenital deformities are encountered who have remained active ambulators. For these rare patients, custom-designed prostheses are required. Lightweight construction can prolong prosthetic use and ambulation (Fig 24A-23.).

SHOES FOR AMPUTEES

It is noteworthy that Kegel reports the recent development of special dress shoes for amputees that are very lightweight, flexible, and have a soft compressible heel to dampen impact at heel strike. The shoes are manufactured by Bally and look like any other regular dress shoe. Kegel states that "there are shoes available for soccer, tennis, skiing and other special requirements, but none for prostheses users." This new development remedies this need.

SUMMARY

The bilateral lower-limb amputee presents complicated problems for mobility and ambulation. The tremendous developments of recent years offer these individuals much greater functional potential. By applying the surgical, prosthetic, and rehabilitation techniques currently available, the bilateral lower-limb amputee can often achieve a remarkable degree of functional ambulation.

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Chapter 24A - Atlas of Limb Prosthetics: Surgical, Prosthetic, and Rehabilitation Principles

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